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A Comparison of the CO2, Argon, and KTP/532 Lasers in the Videolaseroscopic Treatment of Endometriosis
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A Comparison of the CO2, Argon, and KTP/532 Lasers in the Videolaseroscopic Treatment of Endometriosis

Camran Nezhat, Wendy K. Winer, and Farr Nezhat
Colposcopy & Gynecologic Laser Surgery, Vol. 4, No. 1; 1988

Abstract

Several surgical lasers are available currently for laparoscopic use, including the carbon dioxide (CO2), argon, and potassium-titanyl-phosphate (KTP/532 nm) lasers. These lasers each have different properties that offer advantages and disadvantages in the treatment of endometriosis. In the present study, 120 patients with different stages of endometriosis were divided into three groups of 40 patients. Each group underwent videolaseroscopy using one of the three lasers listed above. All three lasers appear to be safe and effective for the laparoscopic treatment of endometriosis. There were no complications experienced, and satisfactory results were obtained in all three groups. This paper discusses and compares the properties of the CO2 , argon, and KTP/532 lasers and the results in each of the three groups of patients. Although the number of patients is too small to make a definite conclusion, it appears that the results of argon and KTP/532 lasers are identical. The outcome for pain relief and fertility appears to be better with CO2 lasers.

A Fresh Look at Ovarian Endometriomas
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A Fresh Look at Ovarian Endometriomas

Farr Nezhat, MD, Ceana Nezhat, MD, Camran Nezhat, MD, & Dahlia Admon, MD
PUBLICATION: Contemporary Ob/Gyn, Vol. 39, No. 11, 11/94

Abstract

Endometriosis of the ovaries has unique manifestations. A new classification of endometriomas offers practical implications for diagnosis and treatment.

A New Approach to Performing Laparoscopic Colposuspension
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A New Approach to Performing Laparoscopic Colposuspension

Goldenberg M, Nezhat C, Mashiach S, Seidman DS.
PUBLICATION: Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, 52621 Tel-Hashomer, Israel.

Abstract

STUDY OBJECTIVE: To assess the role of endometrial resection in preventing recurrence of tamoxifen-associated endometrial polyps in women with breast cancer.

DESIGN: Randomized, prospective study (Canadian Task Force classification I).

SETTING: Tertiary university-affiliated medical center.

PATIENTS: Twenty consecutive women (age range 43-61 yrs).

INTERVENTIONS: Hysteroscopic removal of tamoxifen-associated endometrial polyps with or without simultaneous resection of the endometrium.

MEASUREMENTS AND MAIN RESULTS: Patients were randomized to undergo (10 women) or not undergo (10) concomitant endometrial resection. They were followed for at least 18 months (range 18-24 mo), including transvaginal ultrasonography every 6 months and hysteroscopy when endometrial irregularity was noted. The main outcome variable was recurrence of endometrial polyps; occurrence of uterine bleeding was also noted. In women who underwent endometrial resection, only one had a 1 x 1-cm endometrial polyp diagnosed and removed during follow-up. Seven women remained amenorrheic, and three experienced spotting for a few days every month. In the control group, six women had recurrent endometrial polyps requiring hysteroscopic removal (two-tail Fisher’s exact test p <0.06).

CONCLUSION: Recurrence of endometrial polyps, one of the most common problems in patients with breast cancer receiving long-term treatment with tamoxifen, may be reduced by performing endometrial resection at the time of hysteroscopic removal of polyps. The possible risk of occult endometrial cancer is yet to be determined. (J Am Assoc Gynecol Laparosc 6(3):285-288, 1999)

Related Information: A randomized, prospective study of endometrial resection to prevent recurrent endometrial polyps in women with breast cancer receiving tamoxifen.

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A randomized, prospective study of endometrial resection to prevent recurrent endometrial polyps in women with breast cancer receiving tamoxifen.
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A randomized, prospective study of endometrial resection to prevent recurrent endometrial polyps in women with breast cancer receiving tamoxifen.

Goldenberg M, Nezhat C, Mashiach S, Seidman DS.
 J Am Assoc Gynecol Laparosc. 1999 Aug;6(3):285-8.

Abstract

STUDY OBJECTIVE: To assess the role of endometrial resection in preventing recurrence of tamoxifen-associated endometrial polyps in women with breast cancer.

DESIGN: Randomized, prospective study (Canadian Task Force classification I).

SETTING: Tertiary university-affiliated medical center.

PATIENTS: Twenty consecutive women (age range 43-61 yrs).

INTERVENTIONS: Hysteroscopic removal of tamoxifen-associated endometrial polyps with or without simultaneous resection of the endometrium.

MEASUREMENTS AND MAIN RESULTS: Patients were randomized to undergo (10 women) or not undergo (10) concomitant endometrial resection. They were followed for at least 18 months (range 18-24 mo), including transvaginal ultrasonography every 6 months and hysteroscopy when endometrial irregularity was noted. The main outcome variable was recurrence of endometrial polyps; occurrence of uterine bleeding was also noted. In women who underwent endometrial resection, only one had a 1 x 1-cm endometrial polyp diagnosed and removed during follow-up. Seven women remained amenorrheic, and three experienced spotting for a few days every month. In the control group, six women had recurrent endometrial polyps requiring hysteroscopic removal (two-tail Fisher’s exact test p <0.06).

CONCLUSION: Recurrence of endometrial polyps, one of the most common problems in patients with breast cancer receiving long-term treatment with tamoxifen, may be reduced by performing endometrial resection at the time of hysteroscopic removal of polyps. The possible risk of occult endometrial cancer is yet to be determined. (J Am Assoc Gynecol Laparosc 6(3):285-288, 1999)

Related Information: A randomized, prospective study of endometrial resection to prevent recurrent endometrial polyps in women with breast cancer receiving tamoxifen.

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A rare case of primary extranodal marginal zone B-cell lymphoma of the ovary, fallopian tube, and appendix in the setting of endometriosis
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A rare case of primary extranodal marginal zone B-cell lymphoma of the ovary, fallopian tube, and appendix in the setting of endometriosis

Ceana Nezhat, Erica Dun, Friedrich Wieser, Mauricio Zapata
Am J Obstet Gynecol. 2013 Jan;208(1):e12-4.

Abstract

Extranodal marginal zone B-cell lymphomas are uncommon. Most occur in the gastrointestinal tract. Marginal zone B-cell lymphomas of the female genital tract are rare, and few cases exist of marginal zone B-cell lymphomas of the uterus, cervix, and fallopian tubes. We report the first marginal zone B-cell lymphoma of the ovary, fallopian tube, and appendix arising in endometriosis.

A simplified method of laparoscopic presacral neurectomy for the treatment of central pelvic pain due to endometriosis
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A simplified method of laparoscopic presacral neurectomy for the treatment of central pelvic pain due to endometriosis

Nezhat C, Nezhat F.
 Br J Obstet Gynaecol. 1992 Aug;99(8):659-63.

Abstract

OBJECTIVE: To describe optimal procedures and preliminary results for videolaparoscopic presacral neurectomy as part of the surgical treatment of endometriosis associated with intractable dysmenorrhoea.

DESIGN: Observational study with follow up for at least one year.

SETTING: Subspecialty practice: Endometriosis Clinic and Centre for Special Pelvic Surgery.

SUBJECTS: Eighty five women (18-45 years) with endometriosis and intractable pain, referred because medical and surgical management had failed. Subjects without a central (midline) component to their discomfort were excluded.

INTERVENTIONS: Excision and vaporization of endometriotic pathology was followed by presacral neurectomy.

OUTCOME MEASURES: During surgery, severity of endometriosis was assessed using revised American Fertility Society scoring. Overall pelvic pain and dysmenorrhoea relief were determined by office visit, telephone interview and questionnaire at a minimum of one year postoperatively.

RESULTS: There were no operative complications and all women left hospital within 24 h of surgery. Overall pain relief was reported by 49 (94%) of 52 patients followed. The other three subjects noted no pain abatement. Dysmenorrhoea was reduced in 48 (92%) whereas four (8%) women claimed no relief.

CONCLUSIONS: Laparoscopic presacral neurectomy is an option for treating dysmenorrhoea and pelvic pain in selected women, but is indicated only if medical management has failed. Videolaparoscopic presacral neurectomy using the CO2 laser is safe in trained hands. Pain relief achieved is within the range reported for laparotomy.
PMID: 1390471 [PubMed – indexed for MEDLINE]

Related Information: A simplified method of laparoscopic presacral neurectomy for the treatment of central pelvic pain due to endometriosis

Acute Pulmonary Edema Complicating Diagnostic Laparoscopy Preceded by Thoracotomy
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Acute Pulmonary Edema Complicating Diagnostic Laparoscopy Preceded by Thoracotomy

Howard S. Brown, MD, Farr Nezhat, MD, Camran Nezhat, MD, Jeffrey S. Levy, MD, Michael Maffett, MD

Abstract

We report the case of a patient with pelvic endometriosis and recurrent spontaneous pneumothoraces who had thoracotomy and diagnostic laparoscopy, with subsequent acute pulmonary edema. Potential causes are discussed. After a thorough literature search, we believe this to be the first case in which thoracotomy has been combined with diagnostic laparoscopy.

Adhesion Formation After Endoscopic Posterior Colpotomy
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Adhesion Formation After Endoscopic Posterior Colpotomy

Farr Nezhat, MD, Andrew I. Brill, MD, Ceana H. Nezhat, MD, Camran Nezhat, MD
J. Reproductive Medicine; 0024-7758/93/3087-3534

Abstract

Twenty-two women who had undergone laparoscopic posterior colpotomy at initial operative laparoscopy and later underwent a second laparoscopic procedure were evaluated for adhesion formation. Fifteen women(68%) had myomata removed, 3 (14%) had a dermoid cystectomy, 1 (5%) had a serous cystadenoma removed, and 3 (14%) who had large endometriomata and sever adhesions underwent salpingo-oophorectomy. Although filmy adhesions were noted in nine women, no adhesions were noted in the cul-de-sac. Based on our limited results, it does not appear that tissue removal via laparoscopic colpotomy predisposes reproductive-age women to post-operative adnexal adhesion formation.

Adhesion reformation after reproductive surgery by videolaseroscopy
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Adhesion reformation after reproductive surgery by videolaseroscopy

Nezhat CR, Nezhat FR, Metzger DA, Luciano AA.
 Fertil Steril. 1990 Jun;53(6):1008-11.

Abstract

After initial videolaseroscopy for the treatment of endometriosis-associated infertility, 157 patients underwent a second-look laparoscopy to evaluate and treat recurrence of disease and/or adhesions. The patients were divided into two groups. Group 1 consisted of 135 patients who underwent second-look laparoscopy for persistent infertility and/or recurrence of pain. Group 2 consisted of 22 patients who achieved pregnancy after initial surgery and underwent second-look laparoscopy for evaluation of ectopic pregnancy or in association with uterine evacuation for first trimester spontaneous abortion. Both groups of patients demonstrated a significant reduction in adhesion scores involving the ovaries, tubes, posterior cul-de-sac, anterior cul-de-sac, and omentum/bowel. Although the initial mean adhesion scores were similar for both groups, at second-look laparoscopy the mean adhesion scores were significantly lower for group 2, particularly for ovarian and tubal adhesions. None of the patients formed de novo adhesions. From these results we may conclude that videolaseroscopy: (1) is effective in reducing peritoneal adhesions; (2) is associated with a low frequency of postoperative adhesion recurrence; and (3) appears to completely avoid de novo adhesion formation.
PMID: 2140990 [PubMed – indexed for MEDLINE]
Related Information: Adhesion reformation after reproductive surgery by videolaseroscopy

Aphrodisiacs
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Aphrodisiacs

Robert B. Greenblatt, Jaswant S. Chaddha, Ana Zully Teran, and Ceana H. Nezhat
Psychopharmocology: Recent Advances and Future Prospects.

Abstract

In recent years, pharmacologic agents and hormones have been employed as aphrodisiacs to provoke libidinous drive, enhance or maintain penile erection, and stimulate vaginal lubrication and hyperaemia.

Are the long-term adverse effects of laparoscopic presacral neurectomy for the management of central pain associated with endometriosis acceptable?
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Are the long-term adverse effects of laparoscopic presacral neurectomy for the management of central pain associated with endometriosis acceptable?

Nezhat CH, Seidman DS, Nezhat F, Nezhat C
Prim Care Update Ob Gyns. 1998 Jul 1;5(4):197

Abstract

Objective: To assess the long-term genitourinary and gastrointestinal complaints following presacral neurectomy.Design: A prospective postoperative follow-up of patients who underwent laparoscopic presacral neurectomy and treatment of endometriosis.Materials and Methods: The mean follow-up of the 67 women (mean age 27.5 years, range 16-58 years) was an average of 36.8 months with a range of 6-69 years. Main outcome variables include diarrhea, constipation, bladder and urinary complaints, vaginal dryness, dyspareunia, and orgasm. The degree of pain and dysmenorrhea after surgery was also elevated.Results: Diarrhea was reported to have improved after surgery in 39.1% of the patients and none reported any worsening. Constipation improved in 28.6% and worsened in 12.5%. Only one patient suffered from debilitating constipation. Bladder and urinary problems were improved on 25.0% and worsened in 19.2%. A similar proportion of women (19.6%) reported improvement and worsening vaginal dryness. Pain during intercourse improved in 58.9% and worsened in 8.9%. The ability to achieve orgasm improved in 21.6% and worsened in 2.7%. Postoperatively, pain was improved by 80-100% in 46.6% of the women, by 50-80% in 36.5%, by less than 50% in 6.4%, and did not improve in 9.5%. Dysmenorrhea was improved by 80-100% in 35.2% of the women, by 50-80% in 38.8%, by less than 50% in 14.9%, and did not improve in 11.1%. Twelve of 16 patients trying to become pregnant were successful following surgery, two with the aid of in vitro fertilization.Conclusion: After laparoscopic presacral neurectomy, constipation and bladder and urinary problems were reported to have worsened in only a minority of patients. However, diarrhea and dyspareunia improved in a large proportion of patients. Since pelvic pain was relieved by more than 50% in 83.1%, the procedure seems to be associated with an acceptable rate of long-term side effects.

Case Report: Laparoscopic Treatment of Symptomatic Diaphragmatic Endometriosis
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Case Report: Laparoscopic Treatment of Symptomatic Diaphragmatic Endometriosis

Farr Nezhat, MD, Camran Nezhat, MD, Jeffrey S. Levy, MD
Fertility & Sterility, Vol. 58, No. 3, Sept 1992

Abstract

Several theories currently exist regarding the origin of endometriosis, but none of them have proven singly conclusive and the disease continues to be poorly understood. The location of endometrial implants varies widely and has been found to include such uncommon sites as the appendix, ureter, and lungs. To our knowledge, the following is the first case report describing the laparoscopic treatment of diaphragmatic endometriosis in the vicinity of the phrenic nerve. This type of endometriosis can be successfully treated with extreme caution by experienced laparoscopic surgeons, using CO2 laser vaporization and/or excision and hydrodissection.

Classification of endometriosis. Improving the classification of endometriotic ovarian cysts
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Classification of endometriosis. Improving the classification of endometriotic ovarian cysts.

Nezhat C, Nezhat F, Nezhat C, Seidman DS.
 Hum Reprod. 1994 Dec;9(12):2212-3.

Abstract

Current literature describes 3 different pathogenetic types of ovarian endometriotic cysts. Cortical invagination cysts arise when surface ovarian endometriotic deposits adhere to another structure (such as the broad ligament), blocking the egress of menstrual fluid produced by cycling endometriosis, which then collects and causes the ovarian cortex to invaginate. Surface inclusion cyst-related endometriotic cysts develop when endometriotic tissue colonizes preexisting inclusion cysts. Physiological cyst-related endometriotic cysts occur when endometriosis gains access to a follicle, such as at the time of ovulation. To determine whether routine histological examination is of use in the classification of endometriotic cysts, and if so, whether such classification is of clinical relevance, we reviewed the histology of endometriotic cysts of 29 women under 35 years of age. Young women were chosen so that ovarian cortex surrounding the endometriotic lining in invagination cysts could be identified by the finding of oocytes. Ten women (34%) had cortical invagination endometriotic cysts, but no inclusion or physiological cyst-related endometriomas were found. The remaining 19 women (66%) had unclassified endometriotic cysts, of which 14 (48% of total) had a fibrous wall between the endometriotic lining and medulla and 5 had extensive destruction of ovarian tissue. We concluded that cortical invagination cysts were the only common diagnosable sort of the 3 types currently being investigated and that unclassified cysts required further study to determine their pathogenesis. Our study highlights the need for a prospective study using standardized pathological and clinical methods.
PMID: 11293160 [PubMed – indexed for MEDLINE]
Related Information: Classification of endometriosis. Improving the classification of endometriotic ovarian cysts

Clinical and Histologic Classification of Endometriomas: Implications for a Mechanism of Pathogenesis
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Clinical and Histologic Classification of Endometriomas: Implications for a Mechanism of Pathogenesis

Farr Nezhat, MD, Camran Nezhat, MD, Christopher J. Allan, MD, Deborah A. Metzger, PhD, MD, Donald L. Sears, MD
 J Reprod Med. 1992 Sep;37(9):771-6.

Abstract

One hundred eighty-seven consecutive patients with persistent ovarian cysts and endometriosis underwent laparoscopic evaluation and ovarian cystectomy. All patients had been followed for a minimum of 6 weeks prior to surgery. The cysts were identified initially to be endometriomas based on their gross appearance and the presence of endometriosis at other pelvic sites. Presumed endometriomas were classified into three types based on size, cyst contents, ease of removal of the capsule, adhesions of the cyst to other structures and location of superficial endometrial implants relative to the cyst wall. After clinical laparoscopic classification, the cysts were evaluated histologically without knowledge of the clinical assessment. Histologically small (< 2 cm), superficial ovarian cysts were always endometriomas, and the cyst wall was very difficult to remove (type I). Large cysts with easily removed walls were usually luteal cysts (type II). Large cysts with walls adherent in multiple areas adjacent to superficial endometriosis were generally endometriomas but some also had histologic characteristics of functional (luteal or follicular) cysts (types IIIa and IIIb). These findings led to the conclusion that superficial ovarian endometriosis is similar to endometriosis in extra-ovarian sites in that the formation of superficial cysts is limited in size by fibrosis and scarring. In contrast, large endometriomas may develop as a result of secondary involvement of functional ovarian cysts by the endometriotic process.

Coexistence of endometriosis in women with symptomatic leiomyomas.
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Coexistence of endometriosis in women with symptomatic leiomyomas.


Abstract

OBJECTIVE: To investigate the coexistence of Endometriosis in women presenting with symptomatic Leiomyomas.

DESIGN: Retrospective study.

SETTING: Tertiary university medical center.

PATIENT(S): We reviewed the medical records of 131 patients who underwent laparoscopic Myomectomy or hysterectomy. All patients were consented for possible concomitant diagnosis and treatment of Endometriosis.

INTERVENTION(S): All patients underwent Laparoscopic Myomectomy or hysterectomy.

MAIN OUTCOME MEASURE(S): The main outcome measure of the study was the presence or absence of Endometriosis.

RESULT(S): Of the 131 patients, 113 were diagnosed with Endometriosis and Fibroids, while 18 were diagnosed with Fibroids alone. Patients with Fibroids were on average 4.0 years older than those with Endometriosis and Fibroids (41 vs. 45). Patients with both diagnoses were also more likely to present with pelvic pain and nulliparity than those with Fibroids alone.

CONCLUSION(S): An overwhelming majority of patients with symptomatic Fibroids were also diagnosed with Endometriosis. Overlooking the concomitant diagnosis of Endometriosis in these women may lead to suboptimal treatment of the patients. Further studies are needed to evaluate the impact of surgical treatments on symptom resolution.

Related Information: Coexistence of Endometriosis in women with symptomatic Leiomyomas.

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Comparative Immunohistochemical Studies of bcl-2 and p53 Proteins in Benign and Malignant Ovarian Endometriotic Cysts
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Comparative Immunohistochemical Studies of bcl-2 and p53 Proteins in Benign and Malignant Ovarian Endometriotic Cysts

Nezhat F, Cohen C, Rahaman J, Gretz H, Cole P, Kalir T
Cancer. 2002 Jun 1;94(11):2935-40

Abstract

BACKGROUND: A number of histologic and epidemiologic studies have suggested an association between endometriosis and ovarian carcinoma. Some reports have described a transition from endometriosis to atypical endometriosis to carcinoma. Using immunohistochemistry, the authors compared staining patterns in benign endometriotic cysts with ovarian tumors and the endometriotic cyst lining from which they arose, in an attempt to identify sequential or etiologic correlations.
METHODS: One hundred thirteen formalin-fixed, paraffin-embedded sections were studied (30 benign ovarian endometriotic cysts, 24 endometriotic cysts containing endometrioid carcinomas, 19 endometriotic cysts harboring clear cell carcinomas, and 40 ovarian papillary serous cystadenocarcinomas). All sections were immunostained with anti-bcl-2 and anti-p53 antibodies using the streptavidin-biotin method.
RESULTS: bcl-2 was reported to stain 23% of benign endometriotic cysts, 67% of endometrioid carcinomas, 73% of clear cell carcinomas, and 50% of papillary serous carcinomas. Approximately 42% of benign endometriotic lesions adjacent to the endometrioid carcinoma and 73% adjacent to clear cell carcinomas were found to stain for bcl-2 (p = 0.274 [not significant (NS)] and P = 0.008, respectively). p53 staining was negative in the benign endometriotic cyst group and was positive in 37-55% of the group with tumors. p53 staining was positive in 25% of the benign endometriotic lesions next to the endometrioid carcinoma and in 9% of the benign endometriotic lesions next to clear cell carcinoma (P = 0.014 and P = 0.239 [NS], respectively).
CONCLUSIONS: The results of the current study suggest that alterations in bcl-2 and p53 may be associated with the malignant transformation of endometriotic cysts.

Comparative Immunohistochemical Studies of Endometriosis Lesions and Endometriotic Cysts

Nezhat FR, Kalir T
Fertil Steril. 2002 Oct;78(4):820-4

Abstract

OBJECTIVE: To compare immunohistochemical staining patterns in noncystic and cystic endometriosis lesions.
DESIGN: Experimental.
SETTING: Archived pathology material in an academic research environment.
PATIENT(S): Endometriosis tissues from the pathology archives including slide tissue sections and blocks.
INTERVENTION(S): None; this was a retrospective study.
MAIN OUTCOME MEASURE(S): Immunohistochemical staining of the tissues was performed using anti-bcl-2, anti-p53, anti-matrix metalloproteinase IX, and anti-collagen VI antibodies. Staining was qualitatively assessed in terms of extent and intensity.
RESULT(S): p53 showed no staining in both groups. Anti-bcl-2 stained 100% (30/30) of endometriosis lesions compared with only 23% (7/30) of endometriotic cysts (P<.0001), and anti-matrix metalloproteinase IX stained 85% (23/27) of endometriosis lesions and only 39% (14/36) of endometriotic cysts (P=.0003). Anti-collagen VI, however, stained only 6% (2/35) of endometriosis lesions and 75% (21/28) of endometriotic cysts (P<.0001).
CONCLUSION(S): Compared with endometriosis lesions, endometriotic cysts display different expression of proteins with relative overexpression of collagen VI and underexpression of bcl-2 and metalloproteinase IX. This report is the first comparative immunohistochemical study showing these differences.

Comparison of Direct Insertion of Disposables and Standard Reusable Laparoscopic Trocars and Previous Pneumoperitoneum With Veress Needle
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Comparison of Direct Insertion of Disposables and Standard Reusable Laparoscopic Trocars and Previous Pneumoperitoneum With Veress Needle

Farr R. Nezhat, MD, Sheryl L. Silfen, MD, Debra Evans, LPN, & Camran Nezhat, MD
Obstet Gynecol 78:148, 1991

Abstract

A randomized prospective study was conducted to evaluate the ease of use and safety of direct insertion of laparoscopic trocars. comparison of previous pneumoperitoneum by Veress needle insertion with direct insertion of the reusable conventional laparoscopic trocar and direct insertion of the disposable shielded trocar revealed minor complication rates of 22, 6 and 0%, respectively. No major complications occurred in this series of 200 patients.

Comparison of Transvaginal Sonography and Bimanual Pelvic Examination in Patients with Laparoscopically Confirmed Endometriosis
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Comparison of Transvaginal Sonography and Bimanual Pelvic Examination in Patients with Laparoscopically Confirmed Endometriosis


Abstract

To determine the usefulness of noninvasive clinical tests to diagnose symptomatic endometriosis, we retrospectively reviewed the medical records of 91 patients with chronic pelvic pain and laparoscopically confirmed endometriosis. Thirty-seven women (41%) had pelvic peritoneal endometrial implants with adhesions; in 44 (48%) the ovaries were also affected, and in 10 (11%) the disease involved both the uterus and ovaries. Seventy-nine (87%) women had dysmenorrhea, dyspareunia, or both. Forty-three (47%) had a normal bimanual pelvic examination and 37 (41%) an unremarkable transvaginal sonographic evaluation (no significant difference). The women were divided into two groups: group 1, in whom the disease extended to the ovaries and uterus, and group 2, those in whom only peritoneal implants and adhesions were present. In group 1, 48 women (89%) had an abnormal ultrasonographic evaluation compared with only 4 (11%) in group 2 (p <0.001). our findings indicate that bimanual pelvic examination and transvaginal sonography are equally accurate in detecting endometriosis; however, when the uterine surface and ovaries are involved, the latter is more informative. therefore, patients with chronic pelvic pain, especially pain related to menstruation or coitus, should be evaluated laparoscopically to diagnose mild endometriosis. />
PMID: 9050474 [PubMed – indexed for MEDLINE]

Related Information: Comparison of transvaginal sonography and bimanual pelvic examination in patients with laparoscopically confirmed endometriosis

Complications and Results of 361 Hysterectomies Performed at Laparoscopy
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Complications and Results of 361 Hysterectomies Performed at Laparoscopy

Farr Nezhat, MD, Ceana H. Nezhat, MD, Dahlia Admon, MD, Stephen Gordon, MD, & Camran Nezhat, MD
J. Am. Coll. Surg., 1995, 180:307-16

Abstract

Before the appropriate use of laparoscopy in hysterectomy can be determined, it is necessary to evaluate the results, including complications. There must also be an accepted classification system to facilitate accurate comparison to total abdominal hysterectomy. We retrospectively evaluated the charts of 361 women who underwent hysterectomy for various benign pathologic condition. Intraoperative and postoperative complication rates for hysterectomy performed at operative laparoscopy were examined. The hysterectomies were classified as one of four types according to the number of steps performed laparoscopically. All women were candidates for total abdominal hysterectomy, but not vaginal hysterectomy. The overall complication rate for hysterectomy performed at operative laparoscopy was 11.1%. Most complications were minor, including cystitis (1.66 %), transient high fever (1.39%), abdominal wall ecchymosis (1.12 %), and pneumonia and bronchitis (1.12 %). There was no correlation between the type of laparoscopic hysterectomy performed and the complication rate. Our rate of intraoperative and postoperative complications associated with laparoscopic hysterectomy compares favorably with published complication rates for vaginal and abdominal hysterectomy.

Delayed Recognition of Illiac Artery Injury during Laparoscopic Surgery
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Delayed Recognition of Illiac Artery Injury during Laparoscopic Surgery

Seidman DS, Nasserbakht F, Nezhat F, Nezhat C.
 Surg Endosc. 1996 Nov;10(11):1099-101.

Abstract

Vascular injury is one of the major complications of laparoscopic surgery. Prompt diagnosis is crucial for proper management of this potentially life-threatening complication. Two cases of iliac artery puncture occurred during operative laparoscopy. The injuries were not diagnosed immediately, probably due to the initial accumulation of blood in the retroperitoneum. Significant damage to large blood vessels may not be readily apparent during laparoscopic surgery.

Related Information: Delayed Recognition of Illiac Artery Injury during Laparoscopic Surgery

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Diagnosis and Origins of Endometriomas
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Diagnosis and Origins of Endometriomas

Nezhat C, Nezhat F, Allan CJ, Sears DL.
Fertil Steril. 1995 Feb;63(2):428-30.

Abstract

Comments on:
OBJECTIVE: To describe the characteristics of the endometrial cyst and to locate the implants for selective biopsy.
DESIGN: Prospective study.
SUBJECTS: Fifty-one women with one or two ovarian chocolate cysts of 3 cm or more were investigated.
INTERVENTIONS: Laparoscopy and random biopsy versus a new technique of ovarioscopy and selective biopsy.
MAIN OUTCOME MEASURE: Visual characteristics and histopathology of endometrial cysts.
RESULTS: The clinical suspicion of an endometrioma was confirmed in a series of 59 hemorrhagic cysts by histopathology in 89% and 42%, respectively, of typical and atypical cases and in 27% of recurrent chocolate cysts in the presence of postoperative adhesions. The atraumatic technique of ovarioscopy allowed description of the typical characteristics of the inner wall of the endometrioma and location of the active implants for biopsy. Endometrial tissue was obtained by small ovarioscopy-guided biopsies in 82% of the cases versus 42% in large random biopsies. Red lesions were highly significant for a mucosa-type implant and were predominantly located at the site of invagination stigma and adhesions with the pelvic wall.
CONCLUSIONS: Endoscopy of ovarian chocolate cysts allows observation of typical features of the wall that differentiates it from other benign cysts of the ovary. Microbiopsies obtained under endo-ovarian endoscopy provided significantly more active, endometrial tissue than random biopsies. The data confirm that in most cases the endometrioma is formed by invagination of the cortex and that active implants are located at the site of invagination. Ovarioscopy is therefore proposed as a useful tool to differentiate in doubtful cases between a hemorrhagic functional and an endometriotic cyst and to select the sites for biopsies.
PMID: 8194613 [PubMed – indexed for MEDLINE]
Related Information: Diagnosis and Origins of Endometriomas

Diagnosis of Stage I Endometriosis: Comparing Visual Inspection to Histologic Biopsy Specimen
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Diagnosis of Stage I Endometriosis: Comparing Visual Inspection to Histologic Biopsy Specimen

Kazanegra R, Zaritsky E, Lathi RB, Clopton P, Nezhat C
J Minim Invasive Gynecol. 2008 Mar-Apr;15(2):176-80

Abstract

STUDY OBJECTIVE: To evaluate positive predictive value (PPV) of visual diagnosis at laparoscopy compared with biopsy findings according to severity of endometriosis.
DESIGN: Retrospective study (Canadian Task Force classification II-2).
SETTING: Academic referral center.
PATIENTS: Women who underwent laparoscopic biopsies for suspected endometriosis.
INTERVENTIONS: A total of 238 biopsy specimens (73 endometriomas and 165 peritoneal implants) were taken from 104 patients undergoing laparoscopy for evaluation of chronic pelvic pain thought to be caused by endometriosis.
MEASUREMENTS AND MAIN RESULTS: Accuracy of laparoscopic findings compared with histology-proved endometriosis by severity of disease and location of endometriotic lesions. Overall PPV per patient was 86.5%, which was 75.8% for stage I disease compared with 89.7%, 100%, and 90.6%, respectively, for disease stages II to IV (p = .037). The PPV per biopsy specimen of stages I to IV endometriosis was 66.1%, 78.0%, 92.0%, and 81.1%, respectively (.049). When endometriomas and peritoneal biopsy specimens were analyzed separately, no difference in PPV existed (79% vs 77%; p = .67).
CONCLUSION: High overall PPV existed in our study, especially in patients with advanced disease. The PPV per patient was higher than the PPV per biopsy specimen indicating that ability to diagnose endometriosis may be improved by performing multiple biopsies. This is particularly true in stage I where failure to confirm may be greatest.

Dysmenorrhea is Related to the Number of Implants in Endometriosis Patients
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Dysmenorrhea is Related to the Number of Implants in Endometriosis Patients

Maria Menna Perper, PhD, Ceana H. Nezhat, MD, Farr Nezhat, MD, Camran Nezhat, MD, Harris Goldstein, MD, D.Med.Sc
Fertility and Sterility, 1995;63:500-3

Abstract

To determine whether the symptoms of endometriosis were related to the number and/or location of endometrial implants and the number and/or location of adhesions. Prospective, double-blind study. Seventy consecutive female surgical patients undergoing diagnostic and operative laparoscopy for pain, infertility, or both. Patients completed a self-administered questionnaire one day before laparoscopy. The number, type, and location of endometrial implants and the number, type and location of adhesions were evaluated during laparoscopy. These were compared with the type and severity of endometriosis symptoms as reported by patients. The total number of ectopic endometrial implants was associated directly with the intensity of dysmenorhea experienced by patients in the 60 days before operative laparoscopy (n=47). Patients with low pain scores had significantly fewer implants than patients with high pain scores. The intensity of menstrual pain is related to the number of endometrial implants in patients with endometriosis.

Endometriosis: ancient disease, ancient treatments
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Endometriosis: ancient disease, ancient treatments

Ceana Nezhat, Farr Nezhat, Camran Nezhat
Fertil Steril. 2012 Dec;98(6 Suppl):S1-62.

Related Information:

Endometriosis of The Diaphragm: Four Cases Treated With a Combination of Laparoscopy and Thoracoscopy
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Endometriosis of The Diaphragm: Four Cases Treated With a Combination of Laparoscopy and Thoracoscopy

Nezhat C, Nicoll LM, Bhagan L, Huang JQ, Bosev D, Hajhosseini B, Beygui RE
J Minim Invasive Gynecol. 2009 Sep-Oct;16(5):573-80.

Abstract

STUDY OBJECTIVE: We aim to describe the clinical characteristics and the principles of combined laparoscopic and thoracoscopic management of women with diaphragmatic endometriosis at our institution.
DESIGN: Case series (Canadian Task Force Classification II2).
SETTING: Tertiary care referral center.
PATIENTS: Four women with diaphragmatic endometriosis.
INTERVENTIONS: Laparoscopy and thoracoscopy.
MEASUREMENTS: We retrospectively reviewed the charts of 4 consecutive women with diaphragmatic endometriosis who underwent laparoscopy and thoracoscopy from June 2008 through September 2008.
MAIN RESULTS: Four patients underwent a combination of laparoscopy for treatment of abdominopelvic endometriosis and thoracoscopy for treatment of diaphragmatic endometriosis. All patients had a history of chest pain. Three had a history of pelvic pain. Two had a history of catamenial hemothorax or pneumothorax. Two had been previously diagnosed with endometriosis, and three had a history of hormonal pharmacotherapy. All underwent laparoscopy and thoracoscopy without complications. All had uneventful recoveries. At nine-month follow-up, all patients were free of chest pain, and one patient had recurring pelvic pain.
CONCLUSIONS: To the best of our knowledge, this constitutes the only reported series of patients with endometriosis who underwent a procedure systematically combining both laparoscopy and thoracoscopy for treatment of abdominopelvic and thoracic disease. It confirms that combined laparoscopic and thoracoscopic diagnosis and management of diaphragmatic endometriosis is reasonable. The inferior aspect of the diaphragm should be evaluated in all patients undergoing laparoscopy for endometriosis. Concomitant thoracoscopy should be considered for all patients with history of catamenial hemopneumothorax, cyclic chest or shoulder pain, or cyclic dyspnea. The aim of treatment should be to remove endometriotic lesions, to provide symptomatic relief, and to avoid recurrence. The use of these minimally invasive techniques may reduce the need for laparotomy or thoracotomy in affected patients.

Endometriosis of the Intestine and Genitourinary Tract
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Endometriosis of the Intestine and Genitourinary Tract

Camran Nezhat, MD, Farr Nezhat, MD, Ceana Nezhat, MD
Surgical Technology International 1994, Vol. 3, p. 343-974.

Abstract

As with other organs, the etiology of bowel endometriosis is unknown. Its occurrence was reported as early as 1922 by Sampson. Following his investigation of nineteen cases, he proposed that “implantation adenoma of endometrial type of some portion of the intestinal tract may be present in at least one half of the cases of perforated ovarian hematoma of endometrial type with peritoneal implantations.”

Endometriosis: Insights Into Its Pathogenesis and Treatment
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Endometriosis: Insights Into Its Pathogenesis and Treatment

Azarani A, Osias J, Berker B, Nezhat C, Nezhat C
Surg Technol Int. 2004;12:178-81

Abstract

Clinical and basic science research in endometriosis has been severely hampered by the lack of accurate noninvasive diagnostic tools. The advent of powerful genomic and proteomic technology may help elucidate the etiology and pathophysiology of this complex and enigmatic disease and open new avenues for diagnosis and treatment. Genomic techniques have demonstrated that certain gene products are abnormally expressed in endometriotic tissues.

Endoscopic infertility surgery
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Endoscopic infertility surgery

Nezhat C, Winer WK, Cooper JD, Nezhat F, Nezhat C.
Fertility and Endocrinology Center, Atlanta, Georgia 30342.

Abstract

Since the introduction of endoscopy by Jacobaeus in 1910, there has been a dramatic change in the pattern of and approach to the diagnosis and treatment of various diseases of the female reproductive organs. The advances in techniques of operative endoscopy, in high technology and in instrumentation (such as endoscopes, video cameras and videomonitors) have made it possible to perform laparoscopically many of the infertility-related procedures previously requiring laparotomy. The advantages of such surgery are the rapid recovery time, decreased time lost from work, smaller scars, reduced cost, avoidance of risks and complications of laparotomy, and, perhaps, better results.
PMID: 2522547 [PubMed – indexed for MEDLINE]
Related Information: Endoscopic infertility surgery

Evaluating the risks of electric uterine morcellation
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Evaluating the risks of electric uterine morcellation

Kimberly A. Kho, Ceana H. Nezhat.
JAMA. 2014 Mar 5;311(9):905-6.

Related Information:Evaluating the risks of electric uterine morcellation

Fertility Consideration in Laparopscopic Treatment of Infiltrative Bowel Endometriosis
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Fertility Consideration in Laparopscopic Treatment of Infiltrative Bowel Endometriosis


Abstract

OBJECTIVE:
The purpose of this study was to examine our experience with laparoscopic and laparoscopically assisted management of bowel endometriosis and to recommend treatment approaches, considering patient goals for both pain mitigation or fertility, or both.

METHODS:
The medical records of 187 women treated laparoscopically for intestinal endometriosis were reviewed retrospectively for presenting symptoms, methods of surgical treatment, complications, and efficacy of treating pain and infertility. The extent of resection was determined by the severity of the endometriotic lesion, tempered by the patient’s fertility goals.

RESULTS:
The most common patient complaint preceding surgery was pelvic pain. In addition, 58 (31%) patients experienced impaired fertility. Of the patients available for long-term follow-up, 152 (85%) reported complete or significant long-term pain relief. Complete pain relief in the immediate postoperative period was significantly more likely with partial bowel resection compared with shaving only, 92% vs 80%, respectively, P
Related Information: Fertility Consideration in Laparopscopic Treatment of Infiltrative Bowel Endometriosis

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Fimbrioscopy and salpingoscopy in patients with minimal to moderate pelvic endometriosis
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Fimbrioscopy and salpingoscopy in patients with minimal to moderate pelvic endometriosis

Nezhat F, Winer WK, Nezhat C.
Fertility and Endocrinology Center, Atlanta, Georgia.

Abstract

Fimbrioscopy and salpingoscopy were performed with a rigid salpingoscope during operative laparoscopy in 100 patients with minimal to moderate endometriosis and in 20 normal controls. Five women with endometriosis had perifimbrial adhesions, compared with none of the controls. No subject in either group had adhesion formation of the endosalpinx. These observations indicate that there is no association between endometriosis and intratubal disease.
PMID: 2296415 [PubMed – indexed for MEDLINE]
Related Information: Fimbrioscopy and salpingoscopy in patients with minimal to moderate pelvic endometriosis

Four Ovarian Cancers Diagnosed During Laparoscopic Management of 1011 Women with Adnexal Masses
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Four Ovarian Cancers Diagnosed During Laparoscopic Management of 1011 Women with Adnexal Masses

Farr Nezhat, MD, Camran Nezhat, MD, Charles E. Welander, MD, & Benedict Benigno, MD
Am J Obstet Gynecol, 1992;167:790-6

Abstract

The study was conducted to assess the value of laparoscopic management of adnexa masses. Two concerns we wish to address are the failure to diagnose early ovarian cancer at laparoscopy and worsening the prognosis of stage I cancer by spilling fluid during surgery. All operations were performed in the outpatient surgical suite of a large suburban hospital. After extensive patient screenings, which included history and physical examination, preoperative serum CA-125 levels (since 1988), and pelvic ultrasonography, 1209 adnexal masses were managed laparoscopically. Of 1011 patients with surgical management, ovarian cancer was discovered intraoperatively in four. Our findings indicate that with consistent use of frozen sections of all cyst walls and suspicious tissue, laparoscopic management did not alter the prognosis. Neither CA-125 level, pelvic ultrasonography, nor peritoneal cytologic testing had sufficient diagnostic specificity to predict malignancy. Experienced surgeons using intraoperative histologic sampling may safely evaluate adnexal mass laparoscopically.

Gene Expression Analysis of Endometrium Reveals Progesterone Resistance and Candidate Susceptibility Genes in Women With Endometriosis
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Gene Expression Analysis of Endometrium Reveals Progesterone Resistance and Candidate Susceptibility Genes in Women With Endometriosis

Burney RO, Talbi S, Hamilton AE, Vo KC, Nyegaard M, Nezhat CR, Lessey BA, Giudice LC
Endocrinology. 2007 Aug;148(8):3814-26. Epub 2007 May 17

Abstract

The identification of molecular differences in the endometrium of women with endometriosis is an important step toward understanding the pathogenesis of this condition and toward developing novel strategies for the treatment of associated infertility and pain. In this study, we conducted global gene expression analysis of endometrium from women with and without moderate/severe stage endometriosis and compared the gene expression signatures across various phases of the menstrual cycle. The transcriptome analysis revealed molecular dysregulation of the proliferative-to-secretory transition in endometrium of women with endometriosis. Paralleled gene expression analysis of endometrial specimens obtained during the early secretory phase demonstrated a signature of enhanced cellular survival and persistent expression of genes involved in DNA synthesis and cellular mitosis in the setting of endometriosis. Comparative gene expression analysis of progesterone-regulated genes in secretory phase endometrium confirmed the observation of attenuated progesterone response. Additionally, interesting candidate susceptibility genes were identified that may be associated with this disorder, including FOXO1A, MIG6, and CYP26A1. Collectively these findings provide a framework for further investigations on causality and mechanisms underlying attenuated progesterone response in endometrium of women with endometriosis.

Gynecologic Laparoscopy: Behind the Glass
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Gynecologic Laparoscopy: Behind the Glass

Camran Nezhat, MD, Oleg Bess, MD, Dahlia Adon, MD, Ceana H. Nezhat, MD, & Farr Nezhat, MD
Obstet Gynecol 1994;83:713-6

Abstract

To evaluate and compare the hospital charges for total abdominal hysterectomy (TAH), vaginal hysterectomy, and laparoscopy-assisted vaginal hysterectomy performed with the linear stapler. Thirty cases of each of the three types of hysterectomies, performed at the same hospital by various surgeons, were selected at random. The authors did not participate in any of the cases evaluated. Operating room, postoperative hospitalization, and pharmacy costs were compared. Independent, two-tailed Student t test analysis was performed. The mean cost of performing laparoscopy-assisted vaginal hysterectomy with the linear stapler ($7161.66) was significantly higher (P< .05) than that of both vaginal hysterectomy ($4868.06) and TAH ($4926.80). The cost of vaginal hysterectomy was nonsignificantly lower (P > .05) than that of TAH. The mean operating room supplies and equipment charge for laparoscopy-assisted vaginal hysterectomy with the linear stapler ($2468.43) was, as expected, significantly higher (P< .05) than those for both abdominal ($761.65) and vaginal ($676.16) procedures. The average operating room time charge for laparoscopy assisted vaginal hysterectomy ($1264.56) was also significantly higher (P< .05) than for the other two procedures (TAH $642.76, vaginal hysterectomy $955.66). The mean total pharmacy charges were similar for all groups ($1114.27 for laparoscopy-assisted vaginal hysterectomy, $1163.16 for vaginal hysterectomy, and $1098.71 for TAH). Reflecting the longer operating time for laparoscopy-assisted vaginal hysterectomy, the intraoperative pharmacy costs were significantly higher for this type ($417.00) than for the TAH patients ($290.62) The difference, however, was almost erased when postoperative pharmacy charges were included, reflecting the lower cost of a shorter hospital stay in the laparoscopy-assisted vaginal hysterectomy group. Some savings were realized by laparoscopy-assisted vaginal hysterectomy when postoperative hospitalization charges were considered. The average hospitalization time was 2.3 days for laparoscopy-assisted vaginal hysterectomy, 3.0 days for vaginal hysterectomy, and 3.3 for TAH. The cost savings expected with the advent of laparoscopy-assisted vaginal hysterectomy when performed with the linear stapler have not been realized at present. In most cost categories studied, the use of laparoscopy to perform a hysterectomy was associated with much higher costs. The predicted savings associated with the shorter hospital stay in these patients failed to offset the exorbitant intraoperative costs. However, when bipolar electrocoagulation with the CO2 laser and reusable instrument replace staplers and disposables, respectively, the projected savings are appreciated.

Hematoureter due to endometriosis
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Hematoureter due to endometriosis

Nisha Lakhi, Erica Dun, Ceana Nezhat
Endocrinology. 2007 Aug;148(8):3814-26. Epub 2007 May 17

Abstract

OBJECTIVE: To report the laparoscopic management of a rare case of hematoureter due to endometriosis in a young woman with multiple genitourinary anomalies.
DESIGN: Video demonstration of a surgical technique and review of genitourinary
endometriosis.
SETTING: Hospital.
PATIENT(S): A 17-year-old nulliparous woman with multiple genitourinary anomalies presented with pelvic pain and unilateral retroperitoneal mass. The patient had uterine didelphys, a history of left nephrectomy, and partial ureter resection as an infant. She had a partial resection of a left transverse vaginal septum due to hematocolpos at age 12. A preoperative magnetic resonance imaging (MRI) scan revealed a left retroperitoneal mass with extension to the paravesical region, reaccumulation of the hematocolpos behind the partially resected left transverse vaginal septum, and a dilated left uterine horn with hematometra.
INTERVENTION(S): Laparoscopic management of hematoureter due to intrinsic endometriosis.
MAIN OUTCOME MEASURE(S): Intraoperative findings showed uterus didelphys with dilated left horn, normal right horn, and normal right and left fallopian tubes and ovaries. The left transverse vaginal septum was resected vaginally, and the hematocolpos and hematometra drained. The left uterine horn and cervix were laparoscopically resected. The left-side serpiginous retroperitoneal mass was dissected from the pelvic sidewall, ligated, and transected, with spillage of thick, brown liquid. The pathology of the mass wall was smooth muscle and transitional epithelium consistent with ureter, in addition to hemorrhage and glandular structures consistent with endometriosis. Endometriosis was also present in the serosa of the left uterine horn. Thus, the left retroperitoneal mass was the left ureter remnant, which acquired endometriosis and collected menstrual debris, resulting in hematoureter.
CONCLUSION(S): Two major pathologic types of ureteral endometriosis have been described: intrinsic, as occurred in this patient, and extrinsic. Women with müllerian anomalies, vaginal obstruction, or imperforate hymen are at higher risk of endometriosis. Prior urogenital surgery can further complicate and distort the anatomy. Thus, a preoperative understanding of the patient’s urogenital anomalies is important to consider the differential diagnoses and anticipate surgical needs.

Hospital Cost Comparison Between Abdominal, Vaginal, and Laparoscopy-Assisted Vaginal Hysterectomies
MORELESS

Hospital Cost Comparison Between Abdominal, Vaginal, and Laparoscopy-Assisted Vaginal Hysterectomies

Camran Nezhat, MD, Oleg Bess, MD, Dahlia Adon, MD, Ceana H. Nezhat, MD, & Farr Nezhat, MD
Obstet Gynecol 1994;83:713-6

Abstract

To evaluate and compare the hospital charges for total abdominal hysterectomy (TAH), vaginal hysterectomy, and laparoscopy-assisted vaginal hysterectomy performed with the linear stapler. Thirty cases of each of the three types of hysterectomies, performed at the same hospital by various surgeons, were selected at random. The authors did not participate in any of the cases evaluated. Operating room, postoperative hospitalization, and pharmacy costs were compared. Independent, two-tailed Student t test analysis was performed. The mean cost of performing laparoscopy-assisted vaginal hysterectomy with the linear stapler ($7161.66) was significantly higher (P< .05) than that of both vaginal hysterectomy ($4868.06) and TAH ($4926.80). The cost of vaginal hysterectomy was nonsignificantly lower (P > .05) than that of TAH. The mean operating room supplies and equipment charge for laparoscopy-assisted vaginal hysterectomy with the linear stapler ($2468.43) was, as expected, significantly higher (P< .05) than those for both abdominal ($761.65) and vaginal ($676.16) procedures. The average operating room time charge for laparoscopy assisted vaginal hysterectomy ($1264.56) was also significantly higher (P< .05) than for the other two procedures (TAH $642.76, vaginal hysterectomy $955.66). The mean total pharmacy charges were similar for all groups ($1114.27 for laparoscopy-assisted vaginal hysterectomy, $1163.16 for vaginal hysterectomy, and $1098.71 for TAH). Reflecting the longer operating time for laparoscopy-assisted vaginal hysterectomy, the intraoperative pharmacy costs were significantly higher for this type ($417.00) than for the TAH patients ($290.62) The difference, however, was almost erased when postoperative pharmacy charges were included, reflecting the lower cost of a shorter hospital stay in the laparoscopy-assisted vaginal hysterectomy group. Some savings were realized by laparoscopy-assisted vaginal hysterectomy when postoperative hospitalization charges were considered. The average hospitalization time was 2.3 days for laparoscopy-assisted vaginal hysterectomy, 3.0 days for vaginal hysterectomy, and 3.3 for TAH. The cost savings expected with the advent of laparoscopy-assisted vaginal hysterectomy when performed with the linear stapler have not been realized at present. In most cost categories studied, the use of laparoscopy to perform a hysterectomy was associated with much higher costs. The predicted savings associated with the shorter hospital stay in these patients failed to offset the exorbitant intraoperative costs. However, when bipolar electrocoagulation with the CO2 laser and reusable instrument replace staplers and disposables, respectively, the projected savings are appreciated.

Iatrogenic myomas: new class of myomas?
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Iatrogenic myomas: new class of myomas?

Ceana Nezhat, Kimberly Kho
J Minim Invasive Gynecol. 2010 Sep-Oct;17(5):544-50.

Abstract

Parasitic myomas, defined as extrauterine seeding of leiomyoma, have been reported since the early 1900s. These myomas were thought to be spontaneously occurring, separate from the uterus but still hormone-dependent and can cause symptoms. What seemed to be a rare disorder developing from the natural history of pedunculated myomas has become increasingly reported over the last decade.
Because it is still a rare disorder, the literature is limited to case reports. Herein, we review the literature and provide an analytic review of recent case reports, with emphasis on etiology, trends, and risk factors, to increase awareness of this problematic entity.

Immunoreactive Gonadotropin-Releasing Hormone Expression in Cycling Human Endometrium of Fertile Patients
MORELESS

Immunoreactive Gonadotropin-Releasing Hormone Expression in Cycling Human Endometrium of Fertile Patients

Casañ EM, Raga F, Kruessel JS, Wen Y, Nezhat C, Polan ML.
Fertil Steril. 1998 Jul;70(1):102-6.

Abstract

OBJECTIVE: To investigate the protein expression of GnRH in the endometrium of fertile patients throughout the menstrual cycle.
DESIGN: Prospective longitudinal study.
SETTING: Department of Gynecology and Obstetrics, Reproductive Immunology Laboratory, Stanford University Medical Center.
PATIENT(S): Twenty-two fertile premenopausal women submitted to laparoscopic surgery for benign gynecologic indications. None of the 22 women had endometriosis or pelvic inflammatory disease.
INTERVENTION(S): An endometrial biopsy specimen using the Novak curette was obtained at the time of surgery.
MAIN OUTCOME MEASURE(S): Protein expression and localization from unfractioned endometrial tissue was analyzed by immunohistochemistry.
RESULT(S): Gonadotropin-releasing hormone is expressed at the protein level in both the endometrial stroma and epithelium throughout the entire menstrual cycle of fertile women. Immunostaining in the human epithelium reached maximal levels in the midluteal phase and was elevated in the stroma throughout the entire luteal phase.
CONCLUSION(S): Our results demonstrate the presence of GnRH in the human endometrium at the protein level throughout the entire menstrual cycle of fertile women, with an increase in the luteal phase compared with the preovulatory endometrium.

Incidental Appendectomy During Videolaseroscopy
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Incidental Appendectomy During Videolaseroscopy

Camran Nezhat, MD, & Farr Nezhat, MD
Am J Obstet Cynecol 1991; 165:559-64

Abstract

One hundred incidental appendectomies were performed in patients undergoing operative laparoscopy (videolaseroscopy) for evaluating and treating various major diseases of the reproductive organs. Except for a fever resolving within 24 hours in one case and mild periumbilical ecchymosis, there were no intraoperative or postoperative complications. All patients were discharged within 24 hours of surgery. Average hospital stay was 14 hours. All cases have been followed up for a minimum of 8 months. We believe any risk associated with elective appendectomy as reported here is minimal and outweighed by the benefits of eliminating future emergency appendectomy, simplifying future differential diagnosis of pelvic pain and removing unsuspected abnormality found in the appendix.

Incisional Hernia on the 5-mm Trocar Port Site and Subsequent Wall Endometriosis on the Same Site: A Case Report
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Incisional Hernia on the 5-mm Trocar Port Site and Subsequent Wall Endometriosis on the Same Site: A Case Report

Sirito R, Puppo A, Centurioni MG, Gustavino C
Am J Obstet Gynecol. 2005 Sep;193(3 Pt 1):878-80

Abstract

A 26-year-old nulliparous woman underwent a laparoscopy to remove a 10-cm endometrial cyst on the left ovary (type II Nezhat). The cyst was extracted from the 10-mm umbilical incision; the other 2 trocars were inserted through 5-mm incisions. One year later, in correspondence to the previous 5-mm incision site, a hernia occurred that contained omentum and was reduced easily with a local anesthetic. After 2 years of good health, an aching nodule occurred on the same trocar site; vaginal ultrasound examination showed another left ovarian cyst. A second laparoscopy was performed; the cyst was very adherent and was removed in fragments. The wall nodule was removed, and the histologic examination classified it as endometriosis.

Incisional Hernias After Operative Laparoscopy
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Incisional Hernias After Operative Laparoscopy

Ceana Nezhat, MD, Farr Nezhat, MD, Daniel S. Seidman, MD, and Camran Nezhat, MD
Journal of Laparoendoscopic & Advanced Surgical Techniques Volume 7, Number 2, April 1997

Abstract

The objective of the study was to determine the possible risk factors of incisional hernias after operative laparoscopy. A retrospective case review was performed in a single referral obstetrics/gynecology clinic and center for special pelvic surgery considering the last 5300 surgeries. Of the approximately 5300 patients who underwent laparoscopy from January 1988 through June 1996, 10 women were evaluated for incisional hernias. A total of 11 hernias occurred, which is an incidence of approximately 0.2%. Omentum herniated in seven cases and bowel herniated in four cases. In one case, the sigmoid epiploica irreducibly herniated through the peritoneum and not the fascia. The hernia occurred through a 5mm trocar incision site in five cases. The median duration of the laparoscopic surgeries was 192 minutes (range, 25-375 minutes). Six women required laparoscopic surgery in order to retract the entrapped omentum or bowel. In one case, laparoscopically assisted bowel resection was necessary. The underlying fascia and peritoneum should be closed not only when using trocars of 10mm and larger as previously suggested but also when extensive manipulation is performed through a 5mm trocar port, causing extension of the incision.

Increased Mitogen-Activated Protein Kinase Kinase/Extracellularly Regulated Kinase Activity in Human Endometrial Stromal Fibroblasts of Women With Endometriosis Reduces 3′,5′-Cyclic Adenosine 5′-Monophosphate Inhibition of Cyclin D1
MORELESS

Increased Mitogen-Activated Protein Kinase Kinase/Extracellularly Regulated Kinase Activity in Human Endometrial Stromal Fibroblasts of Women With Endometriosis Reduces 3′,5′-Cyclic Adenosine 5′-Monophosphate Inhibition of Cyclin D1

Velarde MC, Aghajanova L, Nezhat CR, Giudice LC.
Endocrinology. 2009 Oct;150(10):4701-12. Epub 2009 Jul 9

Abstract

Endometriosis is characterized by endometrial tissue growth outside the uterus, due primarily to survival, proliferation, and neoangiogenesis of eutopic endometrial cells and fragments refluxed into the peritoneal cavity during menses. Although various signaling molecules, including cAMP, regulate endometrial proliferation, survival, and embryonic receptivity in endometrium of women without endometriosis, the exact molecular signaling pathways in endometrium of women with disease remain unclear. Given the persistence of a proliferative profile and differential expression of genes associated with the MAPK signaling cascade in early secretory endometrium of women with endometriosis, we hypothesized that ERK1/2 activity influences cAMP regulation of the cell cycle. Here, we demonstrate that 8-Br-cAMP inhibits bromodeoxyuridine incorporation and cyclin D1 (CCND1) expression in cultured human endometrial stromal fibroblasts (hESF) from women without but not with endometriosis. Incubation with serum-containing or serum-free medium resulted in higher phospho-ERK1/2 levels in hESF of women with vs. without disease, independent of 8-Br-cAMP treatment. The MAPK kinase-1/2 inhibitor, U0126, fully restored cAMP down-regulation of CCND1, but not cAMP up-regulation of IGFBP1, in hESF of women with vs. without endometriosis. Immunohistochemistry demonstrated the highest phospho-ERK1/2 in the late-secretory epithelial and stromal cells in women without disease, in contrast to intense immunostaining in early-secretory epithelial and stromal cells in those with disease. These findings suggest that increased activation of ERK1/2 in endometrial cells from women with endometriosis may be responsible for persistent proliferative changes in secretory-phase endometrium.

Initial Report of the Carbon Dioxide Laser Laparoscopy Study Group: Complications
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Initial Report of the Carbon Dioxide Laser Laparoscopy Study Group: Complications

Nezhat et al
J Gynecologic Surgery, 5:269, 1989

Abstract

Operative laparoscopy using the CO2 laser is becoming increasingly common in reproductive pelvic surgery. However, to date, characterization of the safety of this technique has been limited. However, to date, characterization of the safety of this technique has been limited. To assess this issue, the reports of the 821 women in the database of the Carbon Dioxide Laser laparoscopy Study Group were reviewed. Procedures performed at laparoscopy included vaporization of endometriosis, adhesiolysis, transection of the uterosacral ligaments, fimbrioplasty, salpingostomy for ectopic pregnancy, ovarian cystectomy, and neosalpingostomy. Ninety (11%) were hospitalized overnight, and 22 (2.6%) were hospitalized two or more nights. Operative complication were limited and consisted of 9 cases of intraabdominal bleeding, 3 women with uterine perforation, 1 with trocar injury to the uterus, and 1 with an omental hemotoma. None of these women required laparotomy. One patient underwent laparotomy to rule out small bowel injury, but none was noted. Postoperative complications reported consisted of 2 women with urinary retention and 1 each with postconization bleeding, periumbilical hematoma, acute infectious colitis, and allergic reaction to i.m. Depo Provera. Thus, operative or postoperative complications attributable to performance of operative CO2 laser laparoscopy per se were rare and without clinically significant morbidity or mortality. It is concluded that in experienced hands, CO2 laser laparoscopy can be safely used in the performance of reproductive pelvic surgery.

Injuries Associated with the Use of a Linear Stapler During Operative Laparoscopy: Review of Diagnosis, Management, and Prevention
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Injuries Associated with the Use of a Linear Stapler During Operative Laparoscopy: Review of Diagnosis, Management, and Prevention

Camran Nezhat, MD, Farr Nezhat, MD, Oleg Bess, MD, Ceana H. Nezhat, MD
J Gynecol Surg 9:145, 1993

Abstract

We report 7 recent examples of intraoperative and postoperative complications and injuries resulting from the use of an automatic stapling device during operative laparoscopy. The cases were collected throughout the United States and represent a cross-section of common complications. This report should alert surgeons to the possibilities of ureteral, bladder, and bowel injuries, postoperative bleeding, and instrument malfunctions. In addition, precautions and techniques to prevent and resolve complications are discussed.

Intracorporeal electromechanical tissue morcellation: a critical review and recommendations for clinical practice
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Intracorporeal electromechanical tissue morcellation: a critical review and recommendations for clinical practice

Kimberly Kho, Ted Anderson, Ceana Nezhat
Obstet Gynecol. 2014 Oct;124(4):787-93.

Abstract

Electromechanical morcellators have come under scrutiny with concerns about complications involving iatrogenic dissemination of both benign and malignant tissues. Although the rapidly rotating blade has resulted in morcellator-related vascular and visceral injuries, equally concerning are the multiple reports in the literature demonstrating seeding of the abdominal cavity with tissue fragmented such as leiomyomas, endometriosis, adenomyosis, splenic and ovarian tissues, and occult cancers of the ovaries and uterus. Alternatives to intracorporeal electric morcellation for tissue extirpation through the vagina and through minilaparotomy are feasible, safe, and have been shown to have comparable, if not superior, outcomes without an increased need for laparotomy. Intracorporeal morcellation within a containment bag is another option to minimize the risk of iatrogenic tissue seeding. Patient safety is a priority with balanced goals of maximizing benefits and minimizing harm. When intracorporeal electromechanical morcellation is planned, physicians should discuss the risks and consequences with their patients. Although data are being collected to quantify and understand these risks more clearly, a minimally invasive alternative to unenclosed intracorporeal morcellation is favored when available. It is incumbent on surgeons to communicate the risks of practices and devices and to advocate for continued improvement in surgical instrumentation and techniques.

Intraoperative Sigmoidoscopy in Gynecologic Surgery
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Intraoperative Sigmoidoscopy in Gynecologic Surgery

Nezhat C, de Fazio A, Nicholson T, Nezhat C.
Atlanta Center for Special Pelvic Surgery, Atlanta, Georgia 30342, USA.

Abstract

Intraoperative sigmoidoscopy is underused by the majority of practicing gynecologists and is not widely taught in obstetrics and gynecology training programs. In this report, a step-by-step approach is provided in order to perform sigmoidoscopy. Indications for use, along with various intraoperative applications, are discussed. Results from our center’s experience with its use during laparoscopic treatment of adhesions, endometriosis, and associated disease of the bowel also are provided. Intraoperative sigmoidoscopy is a safe and efficacious procedure that can aid in the evaluation and treatment of pelvic pathology and facilitate identification and management of bowel injuries. It should be considered a valuable adjunct when such cases are encountered by gynecologic and pelvic surgeons.

Related Information: Intraoperative Sigmoidoscopy in Gynecologic Surgery

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Investigation of often-reported ten percent hysteroscopy fluid overfill: Is this accurate?
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Investigation of often-reported ten percent hysteroscopy fluid overfill: Is this accurate?


Abstract

STUDY OBJECTIVE:
A key component of hysteroscopic complications, such as fluid overload and severe dilutional hyponatremia, is the failure to anticipate and quickly recognize fluid deficits. The purpose of this study was to measure the volume and mass of irrigation fluid bags to assess the overfill of 3 common types of hysteroscopy irrigation fluids, 0.9% normal saline solution, 3% sorbitol, and 1.5% glycine, to challenge the often-quoted standard of assumption that overfill may be as high as 10% of the bag’s volume.

DESIGN: Ten cases of irrigation fluid were tested. The volume and weight of drained fluid from 18 bags of 0.9% normal saline solution 2000 mL, 12 bags 3% sorbitol 3000 mL, 8 bags of 1.5% glycine 3000 mL, and 4 bags of 0.9% normal saline solution 5000 mL were measured. Institutional review board exemption was obtained.

MEASUREMENTS AND MAIN RESULTS: Ten cases of irrigation fluid were obtained. The volume and weight of drained fluid from 18 bags of 0.9% normal saline solution 2000 mL, 12 bags of 3% sorbitol 3000 mL, 8 bags of 1.5% glycine 3000 mL, and 4 bags of 0.9% normal saline solution 5000 mL were measured. By volume, varying by the type of fluid tested, the maximum observed overfill was between 3.3% to 5.0%. For confirmation, each bag was also weighed and found to have a maximum overfill between 2.8% to 5.6%, varying with the volume and type of fluid measured. These findings were then compared with the manufacturer-provided overfill range of 1.5% to 6.0%. No underfill was observed.

CONCLUSION: Contrary to assertions over the last 25 years that overfill is 10% or higher as a rule, it appears more reasonable to assume that the degree of overfill is contingent on the type and volume of fluid used and is more likely closer to 2.8% to 5.6%. Therefore an accurate collecting system and weight measurement is more precise.

Related Information: Investigation of often-reported ten percent hysteroscopy fluid overfill: Is this accurate?

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Is Endoscopic Treatment of Endometriosis and Endometrioma Associated With Better Results Than Laparotomy
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Is Endoscopic Treatment of Endometriosis and Endometrioma Associated With Better Results Than Laparotomy

Camran Nezhat, MD, Wendy K. Winer, RN, BSN, Farr Nezhat, MD;
Am J Gynecologic Health Vol. II, No. 3

Abstract

Endoscopic treatment of endometriosis and endometrioma employing two different techniques was achieved on 20 infertility patients using the laser laparoscope with video augmentation or videolaseroscopy. Results of each technique are discussed.

Is Hormonal Suppression Efficacious in Treating Functional Ovarian Cysts?
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Is Hormonal Suppression Efficacious in Treating Functional Ovarian Cysts?

Nezhat FR, Nezhat CH, Borhan S, Nezhat CR.
Center for Special Pelvic Surgery, 5555 Peachtree-Dunwoody Road, Suite 276, Atlanta, GA 30342.

Abstract

We randomly assigned 95 women, age 17-55 (mean 36.5) with unilateral or bilateral ovarian cysts measuring 1.1 to 6.1 cm in greatest diameter, to four groups to determine the efficacy of hormonal suppression. Eleven did not complete the study, and 9 did not follow up, for a study population of 75. Of these 75, 29 women had a history of endometriosis and 12 were treated with ovulation induction within 6 months of inclusion. Group I (24), received no treatment and served as a control; Group II (15) took oral contraceptives (OCP) containing 35 &mgr;g ethinyl estradiol and 1 mg norethindrone; Group III (23) received OCP’s with 50 &mgr;g ethinyl estradiol and 1 mg norethindrone; and Group IV (13) took danazol 800 mg/day. All medications were taken continuously for 6 weeks. Patients were then re-evaluated by pelvic examination and transvaginal ultrasound. If the cysts persisted, the patient was scheduled for diagnostic and possible operative laparoscopy. Complete resolution of cysts was found in: Group I – 14 (58%), Group II – 6 (40%), Group III – 15 (65%), and Group IV – 7 (54%). Of the 33 women with persistent cysts, 28 underwent videolaparoscopy. The results were as follows: Group I (42%) – five functional, two endometriomas, one hydrosalpinx, and one benign paraovarian serous cyst; Group II (60%) – three functional, one endometrioma, and one benign simple cyst; Group III (35%) – two functional, five endometriomas, and one loop of bowel; and Group IV (46%) – four functional and two endometriomas. The results, analyzed using the chi2 test, indicated that there is no significant difference between expectant management and hormonal suppression in treating functional ovarian cysts. A CA 125 was obtained on 48 women. Using the t-test, we compared values for cysts which persisted and those which did not. There was no correlation between CA 125 levels and persistence or resolution.
PMID: 9073730 [PubMed – as supplied by publisher]
Related Information: Is Hormonal Suppression Efficacious in Treating Functional Ovarian Cysts?

Is Hormonal Treatment Efficacious in the Management of Ovarian Cysts in Women with Histories of Endometriosis?
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Is Hormonal Treatment Efficacious in the Management of Ovarian Cysts in Women with Histories of Endometriosis?

Ceana H. Nezhat, Farr Nezhat, Soheila Borhan, Daniel S. Seidman, & Camran R. Nezhat
Human Reproduction, Vol. 11, No. 4, p.874-77, 1996

Abstract

In a controlled, randomized study, we evaluated the effectiveness of various hormonal regimens in treating 70 women (mean age 34.7 + 5.7 years) who had unilateral or bilateral ovarian cysts presumed to be physiological (functional) and a history of endometriosis. The patients were assigned randomly to one of the following groups: group I (control), no treatment; group II, oral contraceptives (35 ug ethinyl oestradiol and 1 mg norethindrone); group III, oral contraceptives (50 ug ethinyl oestradiol and 1 mg norethindrone); group IV, danazol 800 mg/day. Serum CA-125 concentrations were measured in 32 women. All medications were taken continuously for 6 weeks. Subjects were re-evaluated by pelvic examination and transvaginal ultrasound. Those with persistent cysts were offered diagnostic and possible operative laparoscopy. As 11 patients did not complete the study and five did not follow-up, the final study population comprised 54 women. At 6 weeks follow-up, complete resolution of cysts was found in: group I, 12 out of 18 (66.7%); group II, five out of nine (55.6%); group III, eight out of 14 (57l1%); and group IV, seven out of 13 (53.9%), Two of the 22 women with persistent cysts opted for 6 weeks further medical therapy and achieved complete resolution; 19 underwent laparoscopy, and one was lost to follow-up. All laparoscopic findings revealed benign masses. We found no statistically significant effect when hormonal treatment was compared with expectant management. There was no correlation between serum CA-125 concentrations and the persistence or resolution of cysts.

Laparoscopic Adhesiolysis and Relief of Chronic Pelvic Pain
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Laparoscopic Adhesiolysis and Relief of Chronic Pelvic Pain


Abstract

OBJECTIVE: To evaluate the short- and long-term results of laparoscopic enterolysis in patients with chronic pelvic pain following hysterectomy.

METHODS: Forty-eight patients were evaluated at time intervals from 2 weeks to 5 years after laparoscopic enterolysis. Patients were asked to rate postoperative relief of their pelvic pain as complete/near complete relief (80-100% pain relief), significant relief (50-80% pain relief), or less than 50% or no pain relief.

RESULTS: We found that after 2 to 8 weeks, 39% of patients reported complete/near complete pain relief, 33% reported significant pain relief, and 28% reported less than 50% or no pain relief. Six months to one year postlaparoscopy, 49% of patients reported complete/near complete pain relief, 15% reported significant pain relief, and 36% reported less than 50% or no pain relief. Two to five years after laparoscopic enterolysis, 37% of patients reported complete/near complete pain relief, 30% reported significant pain relief, and 33% reported less than 50% or no pain relief. Some patients required between 1 and 3 subsequent laparoscopic adhesiolysis. A total of 3 enterotomies and 2 cystotomies occurred, all of which were repaired laparoscopically.

CONCLUSION: We conclude that laparoscopic enterolysis may offer significant long-term relief of chronic pelvic pain in some patients.

Related Information: Laparoscopic Adhesiolysis and Relief of Chronic Pelvic Pain

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Laparoscopic Amputation of a Noncommunicating Rudimentary Horn After a Hysteroscopic Diagnosis: A Case Study
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Laparoscopic Amputation of a Noncommunicating Rudimentary Horn After a Hysteroscopic Diagnosis: A Case Study


Abstract

This report describes the diagnosis and management of a noncommunicating rudimentary horn complicated by severe pelvic pain and associated endometriosis. This condition was diagnosed by simultaneous laparoscopic and hysteroscopic examinations. The hysteroscopic evaluation was significant in the diagnosis, as the noncommunicating horn was not recognized during a previous laparoscopy. The laparoscopic removal of the horn afforded complete long-term resolution of pain coupled with speedy postoperative recovery.
PMID: 8180771 [PubMed – indexed for MEDLINE]
Related Information: Laparoscopic amputation of a noncommunicating rudimentary horn after a hysteroscopic diagnosis: a case study

Laparoscopic Appendectomy in Patients with Endometriosis
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Laparoscopic Appendectomy in Patients with Endometriosis


Abstract

STUDY OBJECTIVE: To report the frequency and spectrum of histologically proved diseases of the appendix in patients undergoing laparoscopic surgery for chronic pelvic pain in conjunction with endometriosis in a tertiary referral center.

DESIGN: Patient database with retrospective chart review (Canadian Task Force classification II-3).

SETTING: University ambulatory endoscopic surgery center-tertiary referral center.

PATIENTS: Two hundred thirty-one women.

INTERVENTIONS: Appendectomy during laparoscopic surgery for endometriosis.

MEASUREMENTS AND MAIN RESULTS: We reviewed the medical records of 231 patients who underwent appendectomy during laparoscopic treatment of endometriosis performed from January 1994 through July 2004. Of the 231 patients with pelvic endometriosis, concomitant appendiceal pathology was present in 115.

CONCLUSION: The appendix may be involved and may contribute to pelvic pain in patients with endometriosis.

Related Information: Laparoscopic Appendectomy in Patients with Endometriosis

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Laparoscopic Appraisal of the Anatomic Relationship of the Umbilicus to the Aortic Bifurcation
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Laparoscopic Appraisal of the Anatomic Relationship of the Umbilicus to the Aortic Bifurcation

Nezhat F, Brill AI, Nezhat CH, Nezhat A, Seidman DS, Nezhat C.
Departments of Obstetrics and Gynecology, Standford University School Medicine, California, USA.

Abstract

STUDY OBJECTIVE: To determine the cephalocaudal relationship among the umbilicus, aortic bifurcation, and iliac vessels by direct measurement during laparoscopy.

DESIGN: Prospective, consecutive study (Canadian Task Force classification II-1).

SETTING: Tertiary referral center.

PATIENTS: Ninety-seven women undergoing operative laparoscopy.

INTERVENTIONS: The distance from the aortic bifurcation relative to the umbilicus was measured in both the supine and Trendelenburg positions with a marked suction-irrigator probe. Patients were stratified into three groups based on body mass index (kg/m2). The anatomic location of the common iliac vessels and course of the left common iliac vein were identified in 68 women.

MEASUREMENTS and MAIN RESULTS: The position of the aortic bifurcation ranged from 5 cm cephalad to 3 cm caudal to the umbilicus in the supine position, and from 3 cm cephalad to 3 cm caudal in the Trendelenburg position. In the supine position, the aortic bifurcation was located caudal to the umbilicus in only 11% of patients compared with 33% in the Trendelenburg position. This difference was statistically significant for the total study population (p <0.0001) and for the nonoverweight group (p <0.01). In both positions no significant correlation was found between the distance from the aortic bifurcation to the umbilicus and body mass index. Mean +/- SD distance of the aortic bifurcation from the umbilicus in the supine position was 0.1 +/- 1.2 cm for the nonoverweight group, 0.7 +/- 1.5 cm for the overweight group, and 1. 2 +/- 1.5 cm for the very overweight group. Respective values in Trendelenburg position were 1.0 +/- 1.1, -0.4 +/- 1.2, and -0.2 +/- 1.3 cm. The common iliac artery was caudal to the umbilicus in four women. The space between common iliac arteries was always at least partly occupied by the left common iliac vein, and was completely filled in 19 women (28%).

CONCLUSIONS: The cephalocaudal relationship between the aortic bifurcation and umbilicus varies widely and is not related to body mass index in anesthetized patients. Regardless of body mass index, the aortic bifurcation is more likely to be located caudal to the umbilicus in the Trendelenburg compared with the supine position. Its presumed location can be misleading during Veress needle or primary cannula insertion, and a more reliable guide is necessary for this procedure to avoid major retroperitoneal vascular injury.

Related Information: Laparoscopic Appraisal of the Anatomic Relationship of the Umbilicus to the Aortic Bifurcation

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Laparoscopic disk excision and primary repair of the anterior rectal wall for the treatment of full-thickness bowel endometriosis
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Laparoscopic disk excision and primary repair of the anterior rectal wall for the treatment of full-thickness bowel endometriosis

Nezhat C, Nezhat F, Pennington E, Nezhat CH, Ambroze W.
Department of Obstetrics and Gynecology, Mercer University School of Medicine, Macon, GA 31207.

Abstract

We used a new laparoscopic technique to treat infiltrative symptomatic intestinal endometriosis. Eight women, ages 29-38, with extensive symptomatic pelvic endometriosis were included in this series. All were diagnosed as having severe pelvic endometriosis and had not responded to previous conservative surgical and hormonal therapy. In a 5-18-month postoperative followup, six women have reported complete relief of the symptoms. Two have right lower quadrant pain and menstrual cramping. Second-look laparoscopy was offered to all patients and so far, two have accepted. These procedures were performed 6 weeks postoperatively. At that surgery, we found that the anastomotic site had healed completely with filmy adhesions between the posterior aspect of the uterus and the rectosigmoid colon in one patient. The second woman had undergone extensive adhesiolysis at the first surgery, and these adhesions recurred; however, the anastomotic site had healed completely. One of the two infertility patients has achieved pregnancy. The only complications was one patient with ecchymosis of the anterior abdominal wall. Sigmoidoscopy was performed 6 weeks postoperatively, and has been or will be performed at 6 months postoperatively. To date, all anastomotic sites have healed well with no sign of stricture. Our results with this technique in a small series were positive, and it appears that, in the hands of experienced laparoscopists, it may prove useful in treating symptomatic infiltrative endometriosis.
PMID: 8059307 [PubMed – indexed for MEDLINE]
Related Information: Laparoscopic disk excision and primary repair of the anterior rectal wall for the treatment of full-thickness bowel endometriosis

Laparoscopic Excision of Ovarian Neoplasms Subsequently Found to be Malignant
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Laparoscopic Excision of Ovarian Neoplasms Subsequently Found to be Malignant

Camran Nezhat, MD, Farr Nezhat, MD, Sheryl L. Stilfen, MD, Benedict Benigno, MD, Matthew Burrell, MD, Charles Welander, MD
Obstet Gynecol Vol 78, No. 2, Aug/1991

Abstract

Letter to the editor in reference to article: “Laparoscopic excision of ovarian neoplasms subsequently found to be malignant”, (Obstet Gynecol 1991:77:563-5), Maiman et al surveyed gynecologic oncologists to assess the quality of care and effect on the outcome of ovarian masses initially managed laparoscopically. We would like to suggest that the quality of laparoscopic care in the survey needs to be examined more carefully…

Laparoscopic Hysterectomy and Bilateral Salpingo-oophorectomy Using Multifire GIA Surgical Stapler
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Laparoscopic Hysterectomy and Bilateral Salpingo-oophorectomy Using Multifire GIA Surgical Stapler

Camran Nezhat, MD, Farr Nezhat, MD, & Sheryl L. Silfen, MD
J Gynecol Surg 6:287, 1990

Abstract

A laparoscopic hysterectomy and bilateral salpingo-oophorectomy was performed on a 42-year-old patient with pelvic pain and long-standing endometriosis. A prototype titanium Multifire GIA Stapler, which was designed for use in operative laparoscopy, was used for the first time on this patient, with excellent results.

Laparoscopic Hysterectomy with and without a Robot: Stanford Experience
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Laparoscopic Hysterectomy with and without a Robot: Stanford Experience

Abstract

Laparoscopic Management of 15 Patients with Infiltrating Endometriosis of the Bladder and a Case of Primary Intravesical Endometrioid Adenosarcoma
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Laparoscopic Management of 15 Patients with Infiltrating Endometriosis of the Bladder and a Case of Primary Intravesical Endometrioid Adenosarcoma


Abstract

Objective: To compare robotic-assisted laparoscopic hysterectomy (RALH) with a matched control group of standard laparoscopic hysterectomy (LH).

Methods: A retrospective chart review of all RALH was performed. All cases were compared with a matched control group of standard LH. Comparisons were based on Fisher’s exact, Mann-Whitney, and exact chi-square tests.

Results: Between January 2006 and August 2007, 26 consecutive RALH were performed (10 with bilateral salpingo-oophorectomy). These were compared with 50 matched control standard LH (22 with bilateral salpingooophorectomy). The 2 groups were matched by age (P=0.49), body mass index (P=0.25), gravidity (P=0.11), previous abdomino-pelvic surgery (P=0.37), and size of the excised uterus (P=0.72). Mean surgical time for RALH was 276 minutes (range, 150 to 440) compared with 206 minutes (range, 110 to 420) for standard LH (P=0.01). Blood loss, hospitalization length, and postoperative complications were not significantly different. No conversion to laparotomy was reported in either group.

Conclusion: Robotic technology was successfully used for hysterectomy with a similar surgical outcome to that of standard LH. This technology offers exciting potential applications, especially for remote telesurgery, and to facilitate teaching of endoscopic surgery.

Related Information: Laparoscopic Hysterectomy with and without a Robot: Stanford Experience

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Laparoscopic Management of a Noncommunicating Uterine Horn in a Patient with an Acute Abdomen
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Laparoscopic Management of a Noncommunicating Uterine Horn in a Patient with an Acute Abdomen

D. Paul Amara, MD, Farr Nezhat, MD, Linda Giudice, MD, PhD, & Camran Nezhat, MD
Surgical Laparoscopy & Endoscopy, Vol.7, No.1, pp. 56-59

Abstract

A 13-year-old girl with a history of cloacal anomalies presented with acute abdominal pain. Abdominal ultrasound was not definitive, and vaginal probe ultrasound was precluded by the patients stenotic vagina. Magnetic resonance imaging delineated a left hematometra and hematosalpinx as well as a more normal appearing right hemiuterus. Operative laparoscopy was used to lyse the extensive pelvic adhesions in a patient with a history of an imperforate anus and to resect a left rudimentary uterine horn with outflow obstruction. A review of cases in the world literature reveals that operative laparoscopy can be used to treat these patients successfully.

Laparoscopic Management of a Unicornuate Uterus With Two Cavitated, Non-communicating Rudimentary Horns: Case Report
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Laparoscopic Management of a Unicornuate Uterus With Two Cavitated, Non-communicating Rudimentary Horns: Case Report

Nezhat CR, Smith KS.
Hum Reprod. 1999 Aug;14(8):1965-8

Abstract

An 18 year old nulligravid woman presented with severe dysmenorrhoea secondary to stage IV (revised American Fertility Society) endometriosis, right haematosalpinx, right endometrioma, unicornuate uterus and two cavitated, non-communicating rudimentary uterine horns. To our knowledge, this is the first reported case of a unicornuate uterus accompanied by two rudimentary horns. Operative video-laparoscopy proved a successful approach for treating this previously unreported variant of congenital Müllerian anomaly. A review of the world literature confirms the uniqueness of this case while demonstrating laparoscopy to be a viable alternative to laparotomy for management of congenital Müllerian anomalies. The case presented may help to elucidate Müllerian duct embryology further.

Laparoscopic Management of Genitourinary Endometriosis
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Laparoscopic Management of Genitourinary Endometriosis

Nezhat CR, Nezhat F, Admon D, Seidman D, Nezhat CH.
Clinical Professor Surgery, Gynecology & Obstetrics, Stanford University School of Medicine, Director, Stanford University Endoscopy Center for Training & Technology, 900 Welch Road, Suite 403, Palo Alto, CA 94304.

Abstract

We treated 17 patients with severe endometriosis involving the genitourinary tract. Eight women presented with persistent right or left flank pain, two presented with known ureteral obstruction, and five presented with urinary frequency and burning, and/or hematuria with their periods. Presented are the results of laparoscopic management in these patients. We performed segmental bladder resection in six patients and ureteral resection and reanastomosis in two. Nine additional patients underwent partial resection of the ureteral wall for complete removal of endometrial implants. The ureter was repaired with 4-0 PDS in seven patients and a stent was left in place for 4 to 6 weeks. Two required only a stent due to the small size of the ureterotomy. The postoperative course of these patients was uneventful. Following ureteral repair/reanastomosis, all women underwent an intravenous pyelogram at follow-up, and normal bilateral excretion was demonstrated. Cystoscopy revealed no abnormal findings in five patients who had undergone partial bladder resection. All patients reported significant pain relief or complete resolution of symptoms. Operative laparoscopy can be safely used to achieve relief from severe symptomatic endometriosis of the genitourinary tract.
PMID: 9073728 [PubMed – as supplied by publisher]
Related Information: Laparoscopic Management of Genitourinary Endometriosis

Laparoscopic Management of Hepatic Endometriosis: Report of Two Cases and Review of the Literature
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Laparoscopic Management of Hepatic Endometriosis: Report of Two Cases and Review of the Literature

Nezhat C, Kazerooni T, Berker B, Lashay N, Fernandez S, Marziali M
J Minim Invasive Gynecol. 2005 May-Jun;12(3):196-200

Abstract

Hepatic endometriosis is rare. Only 15 cases have been reported in the literature. All 15 were treated by laparotomy. We report two additional cases of hepatic endometriosis managed for the first time laparoscopically. Endometriosis is a progressive disease especially in women of reproductive age. One of the differential diagnoses of liver endometriosis is malignancy. Currently, there are no reports in the literature regarding complications arising from the progression of hepatic endometriosis. However, this lack of evidence does not deny its existence.

Laparoscopic Management of Intentional and Unintentional Cystotomy
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Laparoscopic Management of Intentional and Unintentional Cystotomy

Ceana H. Nezhat, Daniel S. Seidman, Farr Nezhat, Howard Rottenberg & Camran Nezhat
J Urology, 0022-5347/96/1564-1400

Abstract

With advanced laparoscopic procedures, such as treatment of extensive pelvic adhesions and severe endometriosis, hysterectomy or retropubic urethropexy, there is a risk of bladder injury. The conventional approach to intraperitoneal bladder injury is celiotomy and repair of the perforation in multiple layers. This complication can be treated successfully at laparoscopy regardless of whether partial cystectomy was done intentionally to treat endometriosis or remove ovarian remnants, or the bladder injury was incidental. We summarize the outcome of 19 cases of bladder injury treated laparoscopically.

Laparoscopic Management of Ovarian Dermoid Cysts: Ten Years Experience
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Laparoscopic Management of Ovarian Dermoid Cysts: Ten Years Experience


Abstract

OBJECTIVE: To determine the safety and efficacy of laparoscopic management of ovarian dermoid cysts based upon our ten years’ experience.

METHODS: Charts of 81 patients who underwent laparoscopic removal of dermoid cysts since March 1988 at Stanford University Medical Center or the Center for Special Pelvic Surgery in Atlanta were reviewed retrospectively.

RESULTS: Ninety-three dermoid cysts with a mean diameter of 4.5 cm were removed in 81 patients. Operative techniques used were cystectomy for 70 cysts, salpingooophorectomy for 14, and 9 salpingo-oophorectomy with hysterectomy. Fifty-three cysts were treated via enucleation followed by cystectomy or salpingo-oophorectomy and removal through a trocar sleeve. Twenty-two were treated via enucleation and removal within an impermeable sack. Nine were treated via enucleation and removal by posterior colpotomy. Nine were removed via colpotomy following hysterectomy. We had a total of 39 spillages. Spillage rates varied with removal method: 32 (62%) for trocar removal without an endobag, 3 (13.6%) for removal within an endobag, and 4 (40%) with colpotomy removal. No spillage occurred for the nine patients who had a colpotomy done for hysterectomy. Mean hospital stay after surgery was 0.98 days, and there were no intraoperative complications. In one case, there was a postoperative complication of an incisional infection in the umbilicus.

CONCLUSION: Including this and 13 other studies, review of the literature reveals a 0.2% incidence of chemical peritonitis following laparoscopic removal of dermoid cysts. Thus, we conclude that laparoscopic management of dermoid cysts is a safe and beneficial method in selected patients when performed by an experienced laparoscopic surgeon.

Related Information: Laparoscopic Management of Ovarian Dermoid Cysts: Ten Years Experience

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Laparoscopic Management of Ovarian Remnant
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Laparoscopic Management of Ovarian Remnant

Ceana Nezhat, Susan Kearney, Shazia Malik, Camran Nezhat, Farr Nezhat
Fertil Steril. 2005 Apr;83(4):973-8.

Abstract

OBJECTIVE: To report outcomes of laparoscopic management of patients with ovarian remnant (OR).
DESIGN: Retrospective chart review.

SETTING: Referral practice and tertiary medical center.

PATIENT(S): Sixty-four patients with confirmed OR who underwent laparoscopic treatment between July 1989 and September 2003.

INTERVENTION(S): Laparoscopic excision of OR.

MAIN OUTCOME MEASURE(S): Technical feasibility and recurrence.

RESULT(S): Sixty-nine laparoscopies were performed to remove ovarian remnants, with five patients requiring two laparoscopies. Two cases were converted to laparotomy and one to mini-laparotomy for bowel resection. In 64% (41 out of 64), pelvic mass was diagnosed by imaging (35 by ultrasound, 5 by computerized tomography [CT], and 1 by both). The majority of ovarian remnants were found attached to one or more of the following: ureter, bowel, pelvic sidewall, bladder, rectum, and uterosacral ligament. Intraoperative complications occurred in four cases: three enterotomy and repair; one cystotomy and repair. Twelve minor postoperative complications occurred including urinary tract infection, hematuria, umbilical incision infection, and transient tachycardia. Three major postoperative complications occurred: one umbilical omental hernia, one wound abscess requiring operation, and one vesicovaginal fistula. Adhesions were present in all cases, endometriosis in 55% (35 out of 64), and fibrosis in 30% (19 out of 64).

CONCLUSION(S): In experienced hands, laparoscopic treatment of OR results in acceptable outcomes with its associated advantages over laparotomy.

Related Information: Laparoscopic Management of Ovarian Remnant

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Laparoscopic Management of Pelvic Pathology during Pregnancy
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Laparoscopic Management of Pelvic Pathology during Pregnancy

Tazuke SI, Nezhat FR, Nezhat CH, Seidman DS, Phillips DR, Nezhat CR.
Department of Gynecology and Obstetrics, Stanford University School of Medicine, Stanford, California, USA.

Abstract

Advanced operative laparoscopy is being performed increasingly for various indications and in diverse patient populations, including gravid women. In the United States approximately 1.6% to 2.2% of pregnant women require nonobstetric surgery for abdominal and pelvic pathology. Increasing numbers of case reports suggest the feasibility and safety of operative laparoscopy during pregnancy. We identified certain management issues specific to these procedures based on our experience with nine cases of operative laparoscopy in women with gestations up to 22 weeks.

Related Information: Laparoscopic Management of Pelvic Pathology during Pregnancy

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Laparoscopic Management of Ureteral Endometriosis: The Stanford University Hospital Experience With 96 Consecutive Cases
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Laparoscopic Management of Ureteral Endometriosis: The Stanford University Hospital Experience With 96 Consecutive Cases


Abstract

PURPOSE: We report the clinical characteristics and the principles of laparoscopic management of ureteral endometriosis at our institution. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients with ureteral endometriosis. RESULTS: Preoperatively 97% of patients complained of pain but only a third had urinary symptoms. The left ureter was affected in 64% of cases and disease was bilateral in 10%. Four patients had hydroureter and 2 had hydronephrosis. CONCLUSIONS: To our knowledge this report represents the largest series of laparoscopically treated, pathologically confirmed ureteral endometriotic cases to date. It confirms that laparoscopic diagnosis and management of ureteral endometriosis are safe and efficient. All patients who undergo laparoscopy for endometriosis should be evaluated for possible ureteral involvement regardless of the presence or absence of urinary symptoms, or prior radiological evaluation since undiagnosed ureteral disease may result in loss of renal function.

Laparoscopic Management of Vaginal Clear Cell Adenocarcinoma Arising in Pelvic Endometriosis: Case Report and Literature Review
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Laparoscopic Management of Vaginal Clear Cell Adenocarcinoma Arising in Pelvic Endometriosis: Case Report and Literature Review

Mahdavi A, Shamshirsaz AA, Peiretti M, Zakashansky K, Idrees MT, Nezhat F
J Minim Invasive Gynecol. 2006 May-Jun;13(3):237-41

Abstract

Vaginal clear cell adenocarcinoma arising from pelvic endometriosis has not been reported in the literature. We report a case of a 50-year-old woman with stage I clear cell adenocarcinoma of the vagina who was found to have endometriosis adjacent to the vaginal tumor. She was treated with neoadjuvant chemoradiation, laparoscopically assisted radical vaginal hysterectomy, radical upper vaginectomy, and pelvic lymphadenectomy followed by combination chemotherapy.

Laparoscopic Myomectomy
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Laparoscopic Myomectomy


Abstract

Laparoscopic myomectomy was performed on 154 women, with minimal perioperative complications resulting. Small and single leiomyomata were managed more easily than multiple and larger tumors. Although suturing the excisional sites improved healing, it increased the incidence of adhesion formation. We conclude that laparoscopic myomectomy can be a safe and cost-effective alternative to laparotomy when performed by a skilled operative laparoscopist, but only in selected cases.

Laparoscopic Ovarian Cystectomy During Pregnancy
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Laparoscopic Ovarian Cystectomy During Pregnancy

Farr Nezhat, MD, Camran Nezhat, MD, Sheryl L. Silfen, MD, & Stephen H. Fehnel, MD
J Laparoendoscopic Surgery, Vol. 1, No. 3, 1991

Abstract

A pregnant woman with a history of endometriosis and persistent bilateral adnexal masses underwent laparoscopic ovarian cystectomies at 16 weeks of gestation. There were no adverse sequelae, and the patient had an otherwise uneventful pregnancy and delivery. Operative laparoscopy should be considered to replace laparotomy in appropriate cases during pregnancy.

Laparoscopic Ovarian Surgery
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Laparoscopic Ovarian Surgery

William H. Parker, MD, Farr Nezhat, MD, Michel Canis, MD
J Am Assoc of Gynecologic Laparoscopists, Vol. 1, No. 1, 11/93

Abstract

The following is a summary of an important panel discussion that took place in Chicago, Illinois, at the 21st annual meeting of the American Association of Gynecologic Laparoscopists (AAGL) on September 25, 1992.

Laparoscopic proctectomy for infiltrating endometriosis of the rectum
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Laparoscopic proctectomy for infiltrating endometriosis of the rectum

Nezhat F, Nezhat C, Pennington E.
Center for Special Pelvic Surgery, Fertility and Endoscopy Center, Atlanta, Georgia

Abstract

Proctectomy for deep endometriosis of the rectal wall was performed without laparotomy. Although laparoscopic pelvic surgery and transperineal proctectomy with primary double-stapled anastomosis are established procedures in gynecological and gastrointestinal surgery, this is the first reported case in which these procedures are combined to mobilize the rectum and perform an extracorporeal transanal rectal resection and anastomosis.
PMID: 1533374 [PubMed – indexed for MEDLINE]
Related Information: Laparoscopic proctectomy for infiltrating endometriosis of the rectum

Laparoscopic Radical Hysterectomy and Laparoscopically Assisted Vaginal Radical Hysterectomy with Pelvic and Paraaortic Node Dissection
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Laparoscopic Radical Hysterectomy and Laparoscopically Assisted Vaginal Radical Hysterectomy with Pelvic and Paraaortic Node Dissection

Camran R. NEzhat, MD, Farr R. Nezhat, MD, Matthew O. Burrell, MD, Carlos E. Ramirez, MD, Charles Welander, MD, Jesus Carrodeguas, MD, & Ceana H. Nezhat, MD
J Gynecol Surg, 9:105, 1993

Abstract

Nineteen women underwent laparoscopic radical hysterectomy or laparoscopically assisted vaginal radical hysterectomy, with pelvic node dissection and paraaortic node dissection when indicated. One procedure was converted to laparotomy due to equipment failure (at The University of Puerto Rico). There were two minor postoperative complications. The first, febrile morbidity resulting from a urinary tract infection, responded to medical therapy. The second was incisional bleeding, which was controlled with sutures applied using a local anesthetic. No major postoperative complications were noted, there have been no incidents of recurrence, and the follow-up results are encouraging.

Laparoscopic Radical Hysterectomy with Paraaortic and Pelvic Node Dissection
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Laparoscopic Radical Hysterectomy with Paraaortic and Pelvic Node Dissection

Camran R. Nezhat, MD, Matthey O. Burrell, MD, Farr R. Nezhat, MD, Benedict B. Benigno, MD, & Charles E. Welander, MD
Am J Obstet Gynecol, 1992;166:864-5

Abstract

We report the first case of a laparoscopic radical hysterectomy an paraaortic and pelvic lymphadenectomy to treat a stage IA2 carcinoma of the cervix. To our knowledge, a laparoscopic radical hysterectomy with laparoscopic paraaortic lymphadenectomy has not been previously described.

Laparoscopic Removal of Dermoid Cysts
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Laparoscopic Removal of Dermoid Cysts

Camran Nezhat, MD, Wendy K. Winer, RN, BSN, Farr Nezhat, MD
Obstet Gynecol, 73:278, 1989

Abstract

Nine reproductive-age women underwent removal of unilateral or bilateral dermoid cysts via laparoscopy. Over a follow-up period of 12-42 months, there were no immediate or long-term complications. Four patients have had repeat laparoscopy for evaluation of possible pelvic adhesion formation; one had mild periovarian adhesions and the pelvis appeared normal in the other three.

Laparoscopic Removal of the Cervical Stump after Supracervical Hysterectomy for Persistent Pelvic Pain and Endometriosis
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Laparoscopic Removal of the Cervical Stump after Supracervical Hysterectomy for Persistent Pelvic Pain and Endometriosis

Camran Nezhat, MD, Wendy K. Winer, RN, BSN, Farr Nezhat, MD
Obstet Gynecol, 73:278, 1989

Abstract

Nine reproductive-age women underwent removal of unilateral or bilateral dermoid cysts via laparoscopy. Over a follow-up period of 12-42 months, there were no immediate or long-term complications. Four patients have had repeat laparoscopy for evaluation of possible pelvic adhesion formation; one had mild periovarian adhesions and the pelvis appeared normal in the other three.

Laparoscopic Repair of a Vesicovaginal Fistula: A Case Report
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Laparoscopic Repair of a Vesicovaginal Fistula: A Case Report


Abstract

BACKGROUND: Operative laparoscopy was performed for the management of ovarian remnant syndrome involving the bladder, bowel, vagina, and ureters, and requiring extensive dissection. A vesicovaginal fistula developed postoperatively.

CASE: Because of the complexity and location of the fistula, a vaginal approach was not appropriate. Using techniques of videolaparoscopy, videocystoscopy, and operative laparoscopy, the fistula was repaired.

CONCLUSION: In experienced hands, endoscopic management of complex vesicovaginal fistulas may be an alternative to the traditional abdominal approach.

Related Information: Laparoscopic Repair of a Vesicovaginal Fistula: A Case Report

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Laparoscopic Repair of Gastric Perforation Secondary to Umbilical Trocar Insertion
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Laparoscopic Repair of Gastric Perforation Secondary to Umbilical Trocar Insertion

Abstract

Nezhat CH, de Fazio A, Nezhat CR.
Center for Special Pelvic Surgery, Atlanta, Georgia 30342, USA.
Abstract

A postmenopausal woman was scheduled to undergo laparoscopic treatment of an 8-cm simple ovarian cyst. During abdominal entry, umbilical trocar insertion caused a gastric perforation that was diagnosed immediately and repaired laparoscopically. Following completion of the procedure, the patient was observed for 24 hours with a nasogastric tube in place and was discharged to home on the second postoperative day without further complications. The possibility of gastric distension and perforation is almost always present during laparoscopic abdominal entry. When perforation occurs, repair can be accomplished safely by laparoscopy.

Related Information: Laparoscopic Repair of Gastric Perforation Secondary to Umbilical Trocar Insertion

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Laparoscopic repair of small bowel and colon. A report of 26 cases
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Laparoscopic repair of small bowel and colon. A report of 26 cases

Nezhat C, Nezhat F, Ambroze W, Pennington E.
Center for Special Pelvic Surgery, Atlanta, GA 30342.

Abstract

This is a retrospective review of laparoscopic repair for enterotomies created during therapeutic or diagnostic laparoscopy in 26 women. All patients had mechanical and antibiotic bowel preparation preoperatively. The indication for operative laparoscopy was endometriosis (18), severe abdominal adhesive disease (7), and adhesions with Crohn’s disease (1). Enterotomies were secondary either to CO2 laser vaporization or excision of endometriosis and/or lysis of adhesions (23) and trocar insertion (3). The injuries included small-bowel enterotomies (9), colotomies (4), and rectotomies (13). No clinical complications related to enterotomy repair were noted. Twenty-three patients were discharged 1 day after surgery; one was discharged on postoperative day 2; and two were discharged on postoperative day 3. We concluded that small- and large-bowel enterotomies can be repaired safely via the laparoscope with minimum morbidity in patients with prepared bowel.
PMID: 8456375 [PubMed – indexed for MEDLINE]
Related Information: Laparoscopic repair of small bowel and colon. A report of 26 cases

Laparoscopic repair of ureter resected during operative laparoscopy
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Laparoscopic repair of ureter resected during operative laparoscopy

Nezhat C, Nezhat F.
Department of Obstetrics and Gynecology, Mercer University, Macon, Georgia.

Abstract

Ureteral injury is a recognized complication of gynecologic surgery. During operative laparoscopy performed to treat extensive endometriosis of the pelvic sidewall, a 1.5-cm portion of the right ureter was resected and was repaired successfully. Repair of a resected ureter may be effectively accomplished endoscopically by experienced operative laparoscopists.
PMID: 1386665 [PubMed – indexed for MEDLINE]
Related Informatin: Laparoscopic repair of ureter resected during operative laparoscopy

Laparoscopic Sacral Colpopexy for Vaginal Vault Prolapse
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Laparoscopic Sacral Colpopexy for Vaginal Vault Prolapse

Nezhat CH, Nezhat F, Nezhat C.
Department of Obstetrics and Gynecology, Mercer University School of Medicine, Macon, Georgia.

Abstract

Laparoscopic sacral colpopexy can be used to treat vaginal vault and genital prolapse. After preparation, the vaginal apex is attached to the sacrum over the third and fourth sacral vertebrae using mesh.

Related Information: Laparoscopic Sacral Colpopexy for Vaginal Vault Prolapse

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Laparoscopic segmental bladder resection for endometriosis: a report of two cases
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Laparoscopic segmental bladder resection for endometriosis: a report of two cases

Nezhat CR, Nezhat FR
Department of Obstetrics and Gynecology, Mercer University School of Medicine, Macon, Georgia.

Abstract

BACKGROUND: The proper treatment of bladder endometriosis is unknown.

CASE: Two women with endometriosis involving the full thickness of the bladder wall experienced persistent hematuria during menstruation. They had not responded to previous conservative medical or surgical therapy, so we performed laparoscopic segmental resection, with satisfactory results.

CONCLUSION: Hematuria during menstruation due to endometriosis of the bladder is uncommon. In the two cases presented, good results followed laparoscopic segmental resection.

PMID: 8469507 [PubMed – indexed for MEDLINE]

Laparoscopic Segmental Resection for Infiltrating Endometriosis of the Rectosigmoid Colon: A Preliminary Report
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Laparoscopic Segmental Resection for Infiltrating Endometriosis of the Rectosigmoid Colon: A Preliminary Report

Camran Nezhat, MD, Earl Pennington, MD, and Wayne Ambroze, Jr., MD
Surgical Laparoscopy & Endoscopy, Vol. 2, No. 3, p. 212-16, 1992

Abstract

The following is a description of the first series of laparoscopic partial proctectomies performed without a separate surgical incision. Sixteen women were treated for extensive endometriosis invading the rectal wall. This original series of patients tolerated the procedure well, with no major intraoperative or postoperative complications noted.

Laparoscopic Surgery with a New Tuned High-Energy Pulsed CO2 Laser
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Laparoscopic Surgery with a New Tuned High-Energy Pulsed CO2 Laser

Camran Nezhat, MD, Farr Nezhat, MD
J Gynecol Surg, 8:251, 1992

Abstract

Although CO2 lasers have gained popularity in operative laparoscopy, it has been suggested that they do not deliver sufficiently high power density at the distal end of a laparoscope. Heating of the insufflation gas inside the laparoscope by absorption of some of the laserpower causes the gas density to change and creates distortion and defocusing, resulting in lower power density at the tissue as the laser power is increased. A new laser uses the carbon-13 isotope in the laser gas mix instead of the carbon-12 isotope, which is used in both conventional lasers and CO2 gas. The new laser was found to have no noticeable effect on tissue attributed to distortion or power loss from absorption in the insufflation gas, and it allowed the surgeon to work with minimal thermal side effects, such as the formation of charred tissue. The laser was fitted with separate controls for adjusting pulse energy and average power, allowing the surgeon to control the laser-tissue response at different operating speeds.

Laparoscopic Surgical Management of Diaphragmatic Endometriosis
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Laparoscopic Surgical Management of Diaphragmatic Endometriosis

Nezhat C, Seidman DS, Nezhat F, Nezhat C
Fertil Steril. 1998 Jun;69(6):1048-55

Abstract

OBJECTIVE: To review the clinical presentations of and management options for diaphragmatic endometriosis.

DESIGN: Retrospective review.

SETTING: Referral center.

PATIENT(S): Twenty-four women with endometriosis of the diaphragm.

INTERVENTION(S): Surgical management.

MAIN OUTCOME MEASURE(S): Diagnostic accuracy and therapeutic feasibility of operative laparoscopy.

RESULT(S): Operative findings in 17 patients included 2-5 spots of endometriosis on the diaphragm measuring

CONCLUSION(S): The abdominal diaphragm can be involved with endometriosis and can be diagnosed and treated effectively with the use of videolaparoscopy.

Laparoscopic Trachelectomy for Persistent Pelvic Pain and Endometriosis After Supracervical Hysterectomy
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Laparoscopic Trachelectomy for Persistent Pelvic Pain and Endometriosis After Supracervical Hysterectomy

Nezhat CH, Nezhat F, Roemisch M, Seidman DS, Nezhat C
Fertil Steril. 1996 Dec;66(6):925-8

Abstract

OBJECTIVES: To discuss the safety of laparoscopic removal of the cervical stump after supracervical hysterectomy.

DESIGN: Retrospective review of six cases.

SETTING: Center for Special Pelvic Surgery, a tertiary referral center.

PATIENT(S): Between August 1993 and December 1995, six patients underwent laparoscopic removal of the cervical stump. Their mean age was 43.1 years (range 32 to 56 years). All women had pelvic pain, and one had abnormal bleeding. Three patients had histories of severe endometriosis only, one had extensive endometriosis with adhesions, one had severe adhesions and leiomyomas, and one had all three conditions at hysterectomy.

INTERVENTION(S): Laparoscopic trachelectomy.

MAIN OUTCOME MEASURE(S): Laparoscopic findings and intraoperative and postoperative complications.

RESULT(S): The mean blood loss was 100 mL (range 50 to 200 mL). There were no major intraoperative or postoperative complications.

CONCLUSION(S): Cervical stump removal can be accomplished laparoscopically by an experienced surgeon.

Laparoscopic Treatment of Bowel Endometriosis
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Laparoscopic Treatment of Bowel Endometriosis

Lewis LA, Nezhat C
Surg Technol Int. 2007;16:137-41

Abstract

The most common site of extragenital endometriosis is the intestinal tract, which accounts for approximately 80% of all extragenital endometriosis. The symptoms of intestinal endometriosis are crampy pain, flatulence, painful tenesmus, hyper-peristalsis, progressive constipation, diarrhea alternating with constipation, and occasionally rectal bleeding. As endometriosis in this location often undergoes fibrotic changes, it can be resistant to hormonal therapy, which makes surgical therapy the only option for many women. Until recently, laparoscopic treatment of bowel endometriosis was thought to be impossible. Development of several safe and effective techniques for laparoscopic treatment of intestinal endometriosis has made such treatment possible. In this chapter, the authors describe five proven techniques for treatment of intestinal endometriosis: shaving, disk excision, anterior rectal wall excision, segmental resection, and appendectomy.

Laparoscopic Treatment of Endometriosis with Laser and Videocamera Augmentation (Videolaseroscopy)
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Laparoscopic Treatment of Endometriosis with Laser and Videocamera Augmentation (Videolaseroscopy)

Camran Nezhat, Wendy K. Winer, RN, BSN, Farr Nezhat, MD, & Ceana Nezhat, MD
J of Gynecologic Surgery, 5:163, 1989

Abstract

Recent advances in laparoscopic surgery have enabled the gynecologic surgeon to treat an increased number of diseases of the reproductive organs by using the laser through the laparoscope. This article reviews the results of 857 patients with endometriosis who were treated using the CO2 laser laparoscopically with videocamera augmentation (videolaseroscopy). Of 201 infertility patients followed for at least 18 months, 132 (66%) achieved pregnancy. Of 270 patients with pelvic pain, 210 (77%) patients experienced no pain after 1 year. We conclude that when surgical management of endometriosis is indicated, videolaseroscopy offers advantages over standard laser laparoscopy for the surgeon, including reduced back strain and increased magnification control. In addition, comparable, if not improved, results to the patients can be obtained through laser laparoscopy with video augmentation.

Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal septum endometriosis by the technique of videolaparoscopy and the CO2 laser
MORELESS

Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal septum endometriosis by the technique of videolaparoscopy and the CO2 laser

Nezhat C, Nezhat F, Pennington E.
Department of Obstetrics and Gynecology, Mercer University School of Medicine, Macon, Georgia.

Abstract

OBJECTIVE: To present the technique and results of videolaparoscopy and the CO2 laser as a treatment for deep, infiltrative endometriosis of the rectovaginal septum, uterosacral ligaments, pouch of Douglas and anterior wall of the rectosigmoid colon.

DESIGN: Observational study with 1-5 year follow up.

SETTING: Sub-specialty practice: Endometriosis clinic and centre for special pelvic surgery.

SUBJECTS: 185 women, aged 25-41 years. All had pelvic endometriosis and were referred because of the failure of previous medical and/or surgical treatment.

INTERVENTIONS: Vaporization and excision of endometriotic implants and nodules, ureterolysis, ureteric stents, laparoscopic anterior rectal wall resection and reanastomosis, presacral neurectomy, laparoscopic hysterectomy, salpingo-oophorectomy and appendicectomy using the CO2 laser.

MAIN OUTCOME MEASURES: 174 patients were followed for 1-5 years after surgery by office visit questionnaire or telephone interview. Eleven were lost to follow-up.

RESULTS: 175 patients were discharged within 24 h. Nine with bowel perforations and one with a partial bowel resection were discharged 2-4 days postoperatively. Two patients required ureteric stents, which were removed 6 weeks postoperatively without sequelae. 162 women reported moderate to complete pain relief (145 after one procedure, 13 after two and four after three). 12 reported persistent or worse pain following the surgery. Seven eventually underwent total hysterectomy, four had bowel resections and one had a salpingo-oophorectomy. Of 61 with infertility, 25 achieved pregnancy. Postoperative complications included shoulder pain, anterior abdominal wall ecchymosis, urine retention and dyschezia for one to two weeks.

CONCLUSIONS: Our experience suggests that rectosigmoid colon and infiltrative rectovaginal septum endometriosis can be effectively treated via videolaparoscopy in the hands of experienced endoscopic gynaecologists.

PMID: 1390472 [PubMed – indexed for MEDLINE]

Related Information: Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal septum endometriosis by the technique of videolaparoscopy and the CO2 laser

Laparoscopic Treatment of Obstructed Ureter Due to Endometriosis by Resection and Ureteroureterostomy: A Case Report
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Laparoscopic Treatment of Obstructed Ureter Due to Endometriosis by Resection and Ureteroureterostomy: A Case Report

Camran Nezhat, Farr Nezhat & Bruce Green
J of Urology, Vol 148, 865-868, September 1992

Abstract

Partial ureteral resection and ureteroureterostomy were accomplished using operative laparoscopy in a 36-year-old woman with a long-standing history of endometriosis, left ureteral obstruction and nephrostomy.

Laparoscopic treatment of symptomatic diaphragmatic endometriosis: a case report
MORELESS

Laparoscopic treatment of symptomatic diaphragmatic endometriosis: a case report

Nezhat F, Nezhat C, Levy JS.
Mercer University School of Medicine, Macon, Georgia.

Abstract

Extreme caution and meticulous surgery are imperative when treating the surface of the diaphragm. This procedure should only be performed by an experienced laparoscopic surgeon after appropriate consultation with a cardiothoracic surgeon. Proper care, a thorough understanding of surrounding anatomic structures, and familiarity with laparoscopic instrumentation including the CO2 laser are required for the safe laser vaporization or excision of any peritoneal surface using hydrodissection (7).
PMID: 1387851 [PubMed – indexed for MEDLINE]
Related Information: Laparoscopic treatment of symptomatic diaphragmatic endometriosis: a case report

Laparoscopic Treatment of Type IV Rectovaginal Fistula
MORELESS

Laparoscopic Treatment of Type IV Rectovaginal Fistula

Nezhat CH, Bastidas JA, Pennington E, Nezhat FR, Raga F, Nezhat CR
J Am Assoc Gynecol Laparosc. 1998 Aug;5(3):297-9

Abstract

Fistulas between the anorectum and vagina may arise from several causes. Treatment depends on their etiology and location, as well as the surgeon’s experience. Operative laparoscopy was successful in two women with type IV (mid)rectovaginal fistula in whom previous surgical attempts failed. Our experience suggests that mid and high rectovaginal fistulas can be effectively treated by laparoscopy in the hands of experienced endoscopic surgeons.

Laparoscopic Ureteroneocystostomy and Vesicopsoas Hitch for Infiltrative Endometriosis
MORELESS

Laparoscopic Ureteroneocystostomy and Vesicopsoas Hitch for Infiltrative Endometriosis


Abstract

OBJECTIVE: To report a series of laparoscopic vesicopsoas hitch procedures performed for the treatment of infiltrative ureteral endometriosis.

METHODS: A retrospective chart review of 6 women with severe endometriosis and ureteral obstruction caused by infiltrative disease of the distal ureter was performed. The patients underwent successful laparoscopic ureteroneocystostomy and vesicopsoas hitch.

RESULTS: Five of the 6 patients had a history of endometriosis, and their obstructions were diagnosed during prior surgeries. The other patient was diagnosed with severe endometriosis of the rectum, bladder, and ureter at the time of the procedure. She was referred for evaluation of an incidental finding of hydroureter and hydronephrosis. Three patients were treated with gonadotrophin-releasing hormone (GnRH) analog for at least 3 months preoperatively. Five patients had ureteral stents in place prior to the psoas hitch surgery. No intra- or postoperative complications occurred. All patients had a normal cystogram performed 10 to 14 days postoperatively prior to Foley catheter removal. Stents were kept in place for 6 to 8 weeks, and an intravenous pyelogram (IVP) was done 2 weeks after removal. All patients had a normal renal ultrasound, computer tomography, or intravenous pyelogram at least 1 year postoperatively.

CONCLUSION: Laparoscopic vesicopsoas hitch can be a safe and effective alternative to the laparotomy with the known benefits of laparoscopy.

Related Information: Laparoscopic Ureteroneocystostomy and Vesicopsoas Hitch for Infiltrative Endometriosis

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Laparoscopic Ureteroneocystostomy and Vesicopsoas Hitch with Double Ureter for Infiltrative Endometriosis: A Case Report
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Laparoscopic Ureteroneocystostomy and Vesicopsoas Hitch with Double Ureter for Infiltrative Endometriosis: A Case Report

Nezhat CH, Nezhat F, Seidman D, Nezhat C
Prim Care Update Ob Gyns. 1998 Jul 1;5(4):200

Abstract

BACKGROUND: The incidence of congenital anomalies of the ureter is very low, as is the incidence of endometriosis of the ureter. The presence of the 2 conditions together is extremely rare. To our knowledge, this is the first description in the medical literature of a laparoscopic ureteroneocystostomy and vesicopsoas hitch in the setting of a double ureter for the treatment of infiltrative endometriosis.

CASE: A 31-year-old multigravid woman with a history of severe endometriosis involving the urogenital tract and complete duplication of the right renal collecting system, as well as a right ureterovaginal fistula, presented for evaluation and surgical consult. The patient underwent laparoscopic ureteroneocystostomy and vesicopsoas hitch for the treatment of infiltrative endometriosis with a double ureter.

CONCLUSION: In skilled operative hands, a minimally invasive approach, applying the principles of laparotomy, in the setting of a duplicated renal collecting system is feasible.

Related Information: Laparoscopic Ureteroneocystostomy and Vesicopsoas Hitch with Double Ureter for Infiltrative Endometriosis: A Case Report

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Laparoscopic Ureteroureterostomy: A Prospective Follow-up of 9 Patients
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Laparoscopic Ureteroureterostomy: A Prospective Follow-up of 9 Patients

Nezhat CH, Nezhat F, Seidman D, Nezhat C
Prim Care Update Ob Gyns. 1998 Jul 1;5(4):200

Abstract

Objective: To report the technique and long-term outcome of laparoscopic ureteroureterostomy of injured ureter.Design: A prospective follow-up study.Materials and Methods: Follow-up of nine patients, aged 30-43 years, who acquired intentional ureteral injury during operative laparoscopy for treatment of endometriosis. They were treated between September 1991 and September 1997 by ureteral transection or resection with primary laparoscopic repair by ureteroureterostomy (8 procedures) and ureteroneocystostomy (2 procedures).Results: All operations were successfully completed by operative laparoscopy without need to convert to laparotomy. Estimated blood loss related to the ureteral portion of the procedure was less than 100 mL. Duration of follow-up was between 2 months and 6 years. Follow-up intravenous pyelogram revealed complete healing in seven patients. One patient had mild ureteral stricture, which resolved with transvesical ureteral dilatation, and she is doing well 4 years postoperatively. Another patient with severe endometriosis had recurrent ureteral stricture due to fibrosis distal to the anastomosis site. She underwent laparoscopic ureteroneocystostomy psoas hitch and is doing well 3 months postoperatively.Conclusions: This is the first series of laparoscopic ureter reanastomosis reported to date. The outcome was excellent with low postoperative morbidity typically associated with laparoscopy.

Laparoscopic vaporization of diaphragmatic endometriosis in a woman with epigastric pain: a case report.
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Laparoscopic vaporization of diaphragmatic endometriosis in a woman with epigastric pain: a case report.

Mangal R, Taskin O, Nezhat C, Franklin R.
Woman’s Hospital of Texas and Division of Reproductive Endocrinology, Baylor College of Medicine, Houston, Texas, USA.

Abstract

BACKGROUND: Endometriosis has been observed in 8-15% of reproductive age women and is commonly found in pelvic and nonpelvic organs. Despite its widespread prevalence, the etiology remains obscure.

CASE: A 22-year-old woman with intractable epigastric and pelvic pain who was treated previously by laser ablation for pelvic and diaphragmatic endometriosis was referred to our clinic. The patient received leuprolide acetate for six months, but the symptoms did not improve. Second-look laparoscopy revealed deep endometriotic spots involving both the diaphragms, exactly in the line of the left ventricle. With visualization, endometriosis was excised in total with the help of hydrodissection and CO2 vaporization.

CONCLUSION: As in pelvic endometriosis, therapy for extrapelvic endometriosis consists of surgical and hormonal manipulation following the diagnosis. The importance of extreme caution, meticulous surgery and cardiothoracic consultation when treating the diaphragmatic surface cannot be overemphasized.

Related Information: Laparoscopic vaporization of diaphragmatic endometriosis in a woman with epigastric pain: a case report.

Laparoscopic Versus Abdominal Hysterectomy
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Laparoscopic Versus Abdominal Hysterectomy

Farr nezhat, MD, Camran Nezhat, MD, Stephen Gordon, MD, Elizabeth Wilkins, CST
J of Reproductive Medicine Vol. 37, No. 3, 3/1992

Abstract

The perioperative and postoperative courses of hysterectomy with or without bilateral salpingo-oophorectomy were compared for 10 women who underwent total abdominal hysterectomy and 10 who underwent laparoscopically assisted vaginal hysterectomy. Although laparoscopic hysterectomy took longer (160 versus 102 minutes), the women undergoing it had a shorter duration of hospitalization (2.4 versus 4.4 days), more rapid recuperation (3 vs. 5 wks) and fewer complications. These preliminary results suggest that in the hands of experienced operative laparoscopists, laparoscopically assisted vaginal hysterectomy is preferable to abdominal hysterectomy for selected candidates.

Laparoscopic Vesicopsoas Hitch for Infiltrative Ureteral Endometriosis
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Laparoscopic Vesicopsoas Hitch for Infiltrative Ureteral Endometriosis

Nezhat CH, Nezhat FR, Freiha F, Nezhat CR
Fertil Steril. 1999 Feb;71(2):376-9

Abstract

OBJECTIVE: To report the technique and outcome of a laparoscopic vesicopsoas hitch used for the treatment of infiltrative ureteral endometriosis.

DESIGN: Case report.

SETTING: A tertiary care center.

PATIENT(S): A 36-year-old woman with infiltrative endometriosis of the ureter.

INTERVENTION(S): A laparoscopic vesicopsoas hitch.

MAIN OUTCOME MEASURE(S): The return of normal ureteral function as measured by IV pyelography and ultrasonography.

RESULT(S): After partial ureteral resection, it was noted that a tension-free anastomosis to the bladder was not possible. Thus, a laparoscopic vesicopsoas hitch was performed.

CONCLUSION(S): A vesicopsoas hitch can be performed successfully by laparoscopy.

Laparoscopically assisted anterior rectal wall resection and reanastomosis for deeply infiltrating endometriosis
MORELESS

Laparoscopically assisted anterior rectal wall resection and reanastomosis for deeply infiltrating endometriosis

Nezhat C, Pennington E, Nezhat F, Silfen SL.
Fertility and Endoscopy Center, Atlanta, Georgia.

Abstract

A 28-year-old woman, presented with a history of long-standing, severe pelvic and bowel endometriosis. Pronounced cul-de-sac tenderness and nodularity were noted on pelvic examination. Videolaseroscopy was undertaken, the rectum was mobilized, and the tumor was prolapsed to the level of the anus. Anterior rectal wall resection and reanastomosis were performed; the colon was returned to the pelvis under direct visualization via laparoscope.
PMID: 1669382 [PubMed – indexed for MEDLINE]
Related Information: Laparoscopically assisted anterior rectal wall resection and reanastomosis for deeply infiltrating endometriosis

Laparoscopically-assisted, hysteroscopic removal of an interstitial pregnancy with a fertility-preserving technique
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Laparoscopically-assisted, hysteroscopic removal of an interstitial pregnancy with a fertility-preserving technique

Ceana Nezhat, Erica Dun
J Minim Invasive Gynecol. 2014 Nov-Dec;21(6):1091-4.

Abstract

Described is a novel surgical management of an unruptured interstitial pregnancy with preservation of the ipsilateral fallopian tube and uterine cornua. The patient was a 34-year-old woman, gravida 3, para 1, with an unruptured left interstitial pregnancy at 9 weeks’ gestation, who desired preservation of fertility. The ectopic pregnancy was entirely removed via laparoscopically assisted hysteroscopy with a fertility-preserving surgical technique, with minimal blood loss, preservation of reproductive organs, restoration of anatomy, a patent ipsilateral fallopian tube, and expedient return to normal reproductive function. After the procedure, serial human chorionic gonadotropin levels were obtained until they were PMID: 24768982
Related Information: Laparoscopically-assisted, hysteroscopic removal of an interstitial pregnancy with a fertility-preserving technique

Laparoscopically Assisted Myomectomy: A Report of a New Technique in 57 Cases
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Laparoscopically Assisted Myomectomy: A Report of a New Technique in 57 Cases


Abstract

This study was undertaken to assess the efficacy of a combined operative laparoscopy and minilaparotomy technique to remove single and multiple large leiomyomas. Laparoscopy was used to treat associated pelvic pathology, to identify the leiomyoma(s) and bring it to a minilaparotomy incision and to remove by irrigation blood clots and debris at the end of the procedure. Through this incision, the leiomyoma(s) is grasped, shelled, morcellated, and the uterine defect is repaired in layers. We retrospectively evaluated the records of 57 women who underwent this procedure. The uteri ranged from 8 to 26 weeks’ gestational size. The weight of the leiomyomas ranged from 28 g to 998 g (mean, 247 g); operative time ranged from 40 to 285 minutes (mean, 127 minutes) and blood loss from 50 mL to 1600 mL) (mean, 267 mL). All procedures were completed without full laparotomy. Complications included on case of Klebsiella pneumonia requiring several days of antibiotics, and an incisional hernia at the minilaparotomy site. Forty-one patients were discharged on or before the first postoperative day, 12 on day 2, and four after 72 hours. Most women resumed normal activity within weeks. We found laparoscopically assisted myomectomy to be a safe alternative to myomectomy by laparotomy. It is technically less difficult than laparoscopic myomectomy, allows better closure of the uterine defect, and may require less time to perform.

Laparoscopically-Assisted Hysterectomy for the Management of a Borderline Ovarian Tumor: A Case Report
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Laparoscopically-Assisted Hysterectomy for the Management of a Borderline Ovarian Tumor: A Case Report

Camran Nezhat, MD, Farr Nezhat, MD, Matthew Burrell, MD
J of Laparoendoscopic Surgery, Vol. 2, No. 4, 1992

Abstract

Borderline ovarian tumors account for 4% of ovarian neoplasms, an incidence which remains constant despite advancing age. Management for younger women can be unilateral oophorectomy, although simple hysterectomy with bilateral salpingo-oophorectomy is more appropriate for women beyond childbearing age. The authors report a laparoscopic approach to a case of borderline ovarian tumor.

Laparoscopy During Pregnancy: A Literature Review
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Laparoscopy During Pregnancy: A Literature Review

Nezhat FR, Tazuke S, Nezhat CH, Seidman DS, Phillips DR, Nezhat CR.
Department of Gynecology and Obstetrics, Stanford University School of Medicine, California, USA.

Abstract

OBJECTIVE: To review the literature regarding the role of laparoscopy during pregnancy, particularly adnexal mass and non-obstetric surgery, incorporating the results of a series of 9 cases of laparoscopy during pregnancy at our centers.

MATERIALS AND METHODS: A Medline search was performed to review the literature, and the reference lists provided by those articles were further explored for citations regarding laparoscopic adnexal surgery, appendectomy, and cholecystectomy. Our series of 9 patients consisted of pregnant patients with adnexal mass or acute abdomen who would otherwise have undergone exploratory laparotomy. Follow-up data for these 9 cases were collected by office visits, inquiry to the primary referring physicians, and telephone calls to the patient.

RESULTS: The literature search yielded 42 additional cases of operative pelvic laparoscopy and 51 cases of abdominal operative laparoscopy (cholecystectomy and appendectomy). The publications, particularly regarding cholecystectomy, were supportive of the laparoscopic approach during pregnancy. All of the patients in our series had favorable outcomes.

CONCLUSIONS: Advanced operative laparoscopy has been successfully performed for certain indications during pregnancy.

Related Information: Laparoscopy During Pregnancy: A Literature Review

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Life-Threatening Hypotension After Vasopressin Injection During Operative Laparoscopy, Followed by Uneventful Repeat Laparoscopy
MORELESS

Life-Threatening Hypotension After Vasopressin Injection During Operative Laparoscopy, Followed by Uneventful Repeat Laparoscopy

Farr Nezhat, MD, Dahlia Admon, MD, Ceana H. Nezhat, MD, Joseph E. Dicorpo, MMS, PA, & Camran Nezhat, MD
J of American Association of Gynecologic Laparoscopists, November 1994, Vol2, No. 1

Abstract

Long-Term Outcome of Laparoscopic Presacral Neurectomy for the Treatment of Central Pelvic Pain Attributed to Endometriosis
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Long-Term Outcome of Laparoscopic Presacral Neurectomy for the Treatment of Central Pelvic Pain Attributed to Endometriosis


Abstract

OBJECTIVE: To evaluate the long-term pain reduction achieved by laparoscopic presacral neurectomy.

METHODS: One hundred seventy-six women with median (range) age 30 (18-45) years underwent presacral neurectomy combined with excision and vaporization of endometriotic lesions and were observed, using structured questionnaires, for up to 72 months postoperatively. The study included a convenience sample of the first 100 questionnaires returned. Forty of the women were studied for 12-23 months, and 60 for 24-72 months. The main outcome measures were reduction of pelvic pain, dysmenorrhea, and dyspareunia after surgery.

RESULTS: Pelvic pain, dysmenorrhea, and dyspareunia were reportedly reduced by more than 50% in 74, 61, and 55 patients, respectively, more than 12 months after laparoscopic presacral neurectomy. More than 50% reduction in pelvic pain was reported by 69.8%, 77.3%, 71.4%, and 84.6% of the patients, respectively, with endometriosis stages I-IV, using the revised classification of the American Fertility Society. Comparatively, more than 50% reduction in dysmenorrhea was reported by 52.8% of the patients with stage I endometriosis, 68.2% with stage II, 71.4% with stage III, and 69.2% with stage IV. Reduction of dyspareunia by more than 50% was reported by 54.7% of the patients with stage I endometriosis, 50.0% with stage II, 28.6% with stage III, and 61.5% with stage IV.

CONCLUSION: Long-term outcome of laparoscopic presacral neurectomy is satisfactory in the majority of patients. The stage of endometriosis is not related directly to the degree of pain improvement achieved.

Related Information: Long-Term Outcome of Laparoscopic Presacral Neurectomy for the Treatment of Central Pelvic Pain Attributed to Endometriosis

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Major Retroperitoneal Vascular Injury during Laparoscopic Surgery: Human Reproduction
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Major Retroperitoneal Vascular Injury during Laparoscopic Surgery: Human Reproduction

Nezhat C, Childers J, Nezhat F, Nezhat CH, Seidman DS.
Department of Gynecology and Obstetrics, Stanford University School of Medicine, CA, USA.

Abstract

We sought to assess the outcome of large retroperitoneal vascular injury that occurred during operative laparoscopy but was not related to trocar or Veress needle injury. We conducted a retrospective review of cases operated and reviewed by our centres. Eight cases were identified. Four women were undergoing lymphadenectomy, where vascular injury is a recognized risk. Distorted anatomy was a compounding factor in three of the remaining four patients who were undergoing intraperitoneal procedures. The injuries involved the inferior vena cava (n = 2), the right external iliac artery (n = 2), the left external iliac artery (n = 1), the right external iliac vein (n = 1), the hypogastric artery (n = 1) and the inferior mesenteric artery (n = 1). Injuries were caused by unipolar electrode (n = 1), electrosurgical scissors (n = 3), sharp scissors (n = 2) and CO(2) laser (n = 2). The vessel injury was repaired at laparotomy in four women. The other four cases were managed laparoscopically. Transfusion attributable to the vascular injury occurred in two cases. The outcome in all cases was good, except for one in which the patient died. These cases demonstrate that all energy sources used without proper understanding and caution can cause significant vascular injury. The adequacy and safety of laparoscopic control of major vessel bleeding should be investigated further and consultation with a vascular surgeon should be considered in all cases.

Related Information: Major Retroperitoneal Vascular Injury during Laparoscopic Surgery: Human Reproduction

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Matrix Metalloproteinase-9 and Tissue Inhibitor of Metalloproteinase-3 mRNA Expression in Ectopic and Eutopic Endometrium in Women With Endometriosis: A Rationale for Endometriotic Invasiveness
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Matrix Metalloproteinase-9 and Tissue Inhibitor of Metalloproteinase-3 mRNA Expression in Ectopic and Eutopic Endometrium in Women With Endometriosis: A Rationale for Endometriotic Invasiveness

Chung HW, Wen Y, Chun SH, Nezhat C, Woo BH, Lake Polan M
Fertil Steril. 2001 Jan;75(1):152-9.

Abstract

OBJECTIVE: To investigate mRNA expression of metalloproteinase-9 (MMP-9) and tissue inhibitor of metalloproteinase-3 (TIMP-3) in ectopic endometriosis tissue and uterine endometrium from women with and without endometriosis throughout the menstrual cycle.

DESIGN: Molecular studies in human tissue.

SETTING: Department of Gynecology and Obstetrics, Reproductive Immunology Laboratory, Stanford University Medical Center.

PATIENT(S): Fifty-three premenopausal woman (23 women with endometriosis and 30 women without endometriosis undergoing laparoscopic surgery). Endometrium and ectopic endometriosis tissue were obtained at the time of surgery.

INTERVENTION(S): None.

MAIN OUTCOME MEASURE(S): mRNA expression from eutopic and ectopic endometrium was analyzed by quantitative, competitive PCR.

RESULT(S): Both uterine endometrium and ectopic endometriotic tissue from women with endometriosis expressed significantly (P<.05) lower levels of TIMP-3 than endometrium from normal women. Also, ectopic endometrium expressed higher levels of MMP-9 and a higher ratio of MMP-9/TIMP-3 than eutopic endometrium from normal and endometriosis patients.

CONCLUSION(S): These results suggest that ectopic and eutopic endometrium from endometriosis patients may be more invasive and prone to peritoneal implantation because of greater MMP and less TIMP-3 mRNA expression than endometrium from women without endometriosis. Thus, increased proteolytic activity may be one of the reasons for the invasive properties of the endometrium, resulting in the development of endometriosis.

MicroRNA Expression Profiling of Eutopic Secretory Endometrium in Women With Versus Without Endometriosis
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MicroRNA Expression Profiling of Eutopic Secretory Endometrium in Women With Versus Without Endometriosis

Burney RO, Hamilton AE, Aghajanova L, Vo KC, Nezhat CN, Lessey BA, Giudice LC
Mol Hum Reprod. 2009 Oct;15(10):625-31. Epub 2009 Aug 19

Abstract

Endometriosis is a common gynecologic disorder characterized by pain and infertility. In addition to estrogen dependence, progesterone resistance is an emerging feature of this disorder. Specifically, a delayed transition from the proliferative to secretory phase as evidenced by dysregulation of progesterone target genes and maintenance of a proliferative molecular fingerprint in the early secretory endometrium (ESE) has been reported. MicroRNAs (miRNAs) are small noncoding RNAs that collectively represent a novel class of regulators of gene expression. In an effort to investigate further the observed progesterone resistance in the ESE of women with endometriosis, we conducted array-based, global miRNA profiling. We report distinct miRNA expression profiles in the ESE of women with versus without endometriosis in a subset of samples previously used in global gene expression analysis. Specifically, the miR-9 and miR-34 miRNA families evidenced dysregulation. Integration of the miRNA and gene expression profiles provides unique insights into the molecular basis of this enigmatic disorder and, possibly, the regulation of the proliferative phenotype during the early secretory phase of the menstrual cycle in affected women.

Natural Orifice-Assisted Laparoscopic Appendectomy
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Natural Orifice-Assisted Laparoscopic Appendectomy

Nezhat C, Datta MS, Defazio A, Nezhat F, Nezhat C.
Atlanta Center for Special Minimally Invasive Surgery and Reproductive Medicine, Atlanta, Georgia, USA.

Abstract

BACKGROUND AND OBJECTIVES:
Natural orifice transluminal endoscopic surgery involves the introduction of instruments through a natural orifice into the peritoneal cavity to perform diagnostic and therapeutic surgical interventions. We report the utilization of the vaginal opening at the time of laparoscopic-assisted vaginal hysterectomy or total laparoscopic hysterectomy as a natural orifice for appendectomy.

METHODS:
We reviewed cases of 42 patients who underwent total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy followed by appendectomy, performed by applying a stapler and removing the appendix transvaginally. By using a small-diameter laparoscope, the appendix was mobilized, especially in patients with adhesions, endometriosis, or retrocecal appendix, to facilitate transvaginal access with the stapler.

RESULTS:
All procedures were performed successfully without intraoperative or major postoperative complications. The appendectomy portion of the procedure took approximately 5 minutes to 10 minutes. Appendiceal pathology included serosal adhesions (14), fibrous obliteration of the lumen (12), endometriosis (4), serositis (2), and carcinoid tumor (1), among others.

CONCLUSIONS:
Appendectomy performed with an endoscopic stapler introduced transvaginally for amputation and retrieval following total laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy appears to be a safe and effective modification of established techniques with acceptable outcomes.

Related Information: Natural Orifice-Assisted Laparoscopic Appendectomy

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Nonvisualized endometriosis at laparoscopy
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Nonvisualized endometriosis at laparoscopy

Nezhat F, Allan CJ, Nezhat C, Martin DC.
Department of Obstetrics and Gynecology, Northside Hospital, Atlanta, Georgia.

Abstract

Apparently conflicting results have been reported regarding the incidence, and even the existence, of endometriosis in visually normal peritoneum. The present study was undertaken in view of the fact that the presence and incidence of nonvisualized deep and/or microscopic endometriosis may be of importance in patient management. One patient in this study demonstrated a 1-mm lesion of endometriosis beneath visually normal peritoneum. Two additional patients had cellular surface zones of possible endometrial stroma without a contiguous epithelial component. The results support the existence of unrecognized subperitoneal and microscopic surface endometriosis.
PMID: 1684957 [PubMed – indexed for MEDLINE]
Related Information: Nonvisualized endometriosis at laparoscopy

Novel port placement and 5-mm instrumentation for robotic-assisted hysterectomy.
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Novel port placement and 5-mm instrumentation for robotic-assisted hysterectomy.

Ceana Nezhat, Adi Katz, Erica Dun, Kimberly Kho, Friedrich Wieser
JSLS. 2014 Apr-Jun;18(2):167-73.

Abstract

BACKGROUND AND OBJECTIVES: The value of robotic surgery for gynecologic procedures has been critically evaluated over the past few years. Its drawbacks have been noted as larger port size, location of port placement, limited instrumentation, and cost. In this study, we describe a novel technique for robotic-assisted laparoscopic hysterectomy (RALH) with 3 important improvements: (1) more aesthetic triangular laparoscopic port configuration, (2) use of 5-mm robotic cannulas and instruments, and (3) improved access around the robotic arms for the bedside assistant with the use of pediatric-length laparoscopic instruments.
METHODS: We reviewed a series of 44 women who underwent a novel RALH technique and concomitant procedures for benign hysterectomy between January 2008 and September 2011.
RESULTS: The novel RALH technique and concomitant procedures were completed in all of the cases without conversion to larger ports, laparotomy, or video-assisted laparoscopy. Mean age was 49.9 years (SD 8.8, range 33-70), mean body mass index was 26.1 (SD 5.1, range 18.9-40.3), mean uterine weight was 168.2 g (SD 212.7, range 60-1405), mean estimated blood loss was 69.7 mL (SD 146.9, range 20-1000), and median length of stay was CONCLUSION: Use of the triangular gynecology laparoscopic port placement and 5-mm robotic instruments for RALH is safe and feasible and does not impede the surgeon’s ability to perform the procedures or affect patient outcomes.

PMID: 24960478

Download pdf: Novel port placement and 5-mm instrumentation for robotic-assisted hysterectomy.

Office visceral slide test compared with two perioperative tests for predicting periumbilical adhesions
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Office visceral slide test compared with two perioperative tests for predicting periumbilical adhesions

Ceana Nezhat, Erica Dun, Adi Katz, Friedrich Wieser
Obstet Gynecol. 2014 May;123(5):1049-56.

Abstract

OBJECTIVE: To determine whether the office visceral slide test is an effective screening test for predicting obliterating periumbilical adhesions compared with two ultrasound tests performed in the operating room.
METHODS: Women undergoing benign laparoscopic gynecologic surgery between July 2012 and August 2013 were invited to participate. All participants had an office-based ultrasound test at their preoperative visit (the office visceral slide test), two operating room ultrasound tests (the preoperative examination with visceral slide and the periumbilical ultrasound-guided saline infusion test), and then their scheduled laparoscopic procedure. We measured the ability of the three screening tests to detect obliterating periumbilical adhesions.
RESULTS: Eighty-two women completed the study; 12 women were excluded because they had no history of surgery and 70 women with a history of abdominal and pelvic surgery were analyzed in the study group. The study group (n=70) had a median of two (range, 1-6) previous abdominal surgeries. The median number of previous laparotomies was 0 (range, 0-5). The median number of previous laparoscopies was 1 (range, 0-6). At laparoscopy, 6 of 70 women (8.6%) had periumbilical adhesions diagnosed; 18 of 70 women (25.7%) had any adhesions located in the abdomen or pelvis. The office visceral slide test had a sensitivity of 83.3%, specificity of 100%, positive predictive value of 100%, negative predictive value of 98.5% and diagnostic accuracy of 98.6%.
CONCLUSION: The office visceral slide test is a simple and reliable test for detecting obliterating periumbilical adhesions in the outpatient setting.
LEVEL OF EVIDENCE: II.

PMID: 24785858

Related Information: Office visceral slide test compared with two perioperative tests for predicting periumbilical adhesions

Operative laparoscopy (minimally invasive surgery): state of the art
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Operative laparoscopy (minimally invasive surgery): state of the art

Nezhat C, Nezhat F, Nezhat C.
Department of Obstetrics and Gynecology, Mercer University School of Medicine, Macon, Georgia.

Abstract

In any body cavity, endoscopic surgery is possible and usually preferable. Advantages include better exposure, magnification, and operating very close to the affected tissue. We demonstrate some of the past, present, and future of laparoscopy.

PMID: 10171579 [PubMed – indexed for MEDLINE]

Related Information: Operative laparoscopy (minimally invasive surgery): state of the art

Operative Laparoscopy for the Treatment of Ovarian Remnant Syndrome
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Operative Laparoscopy for the Treatment of Ovarian Remnant Syndrome

Farr Nezhat, MD, Camran Nezhat, MD
Fertility & Sterility, Vol. 57, No. 5, May 1992

Abstract

To present the technique and assess the efficacy of operative laparoscopy to manage ovarian remnant syndrome. Observational with a follow-up of 6 to 32 months. Thirteen women, 9 with previous bilateral salpingo-oophorectomy and 4 with previous unilateral salpingo-oophorectomy and pain on the ipsilateral side. Multipuncture advanced operative laparoscopy. Patient pain relief was assessed through return examinations, telephone interviews, or contact with referring physicians. Nine patients reported complete pain relief. One reported incomplete but satisfactory pain relief. Two required bowel resection by laparotomy to obtain pain relief, and one, despite subsequent laparotomy, had persistent pain. No intraoperative or postoperative complications were noted. Laparoscopy can be effective in managing ovarian remnant syndrome when performed by an experienced laparoscopist.

Operative Laparoscopy. Redefining the Limits
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Operative Laparoscopy. Redefining the Limits


Abstract

The continually changing definition of operative laparoscopy as well as the ever-widening boundaries of its use are discussed in this report. It is important to prepare residents to adequately undertake advanced laparoscopic surgery as laparotomy is gradually replaced by laparoscopy for many routine procedures. Since degree of training and experience strongly correlate with complication rates, more focus on laparoscopy during graduate education would be beneficial to residents in order to keep them up to date with the rapid development of this field.

Related Information: Operative Laparoscopy. RedefIning the Limits

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Ovarian Remnant Syndrome after Laparoscopic Oophorectomy
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Ovarian Remnant Syndrome after Laparoscopic Oophorectomy

Nezhat CH, Seidman DS, Nezhat FR, Mirmalek SA, Nezhat CR
Fertil Steril. 2000 Nov;74(5):1024-8

Abstract

OBJECTIVE:
To report the surgical history, clinical characteristics, and operative technique used in patients with ovarian remnant syndrome after laparoscopic oophorectomy.

DESIGN:
Observational study. SETTING: Teaching hospital and private practice office.

PATIENT(S):
Nineteen patients with documented history of unilateral or bilateral laparoscopic oophorectomies with histologic confirmation of ovarian remnants.

INTERVENTION(S):
Operative laparoscopy for resection of ovarian remnants.

MAIN OUTCOME MEASURE(S):
Risk factors and surgical technique contributing to ovarian remnant syndrome.

RESULT(S):
The patients underwent a mean of 4.7 previous surgical procedures (range, two to nine): 12 had bilateral oophorectomy, and seven had unilateral oophorectomy. The infundibulopelvic ligament had been secured with bipolar desiccation in 11 patients, pretied surgical loops in six, and a linear stapler in two. Cystic ovarian remnants were identified by pelvic sonography in 12 women and by computed tomography (CT) scan in one. Six women underwent reoperation, two for ovarian remnants in different sites.

CONCLUSION(S):
With laparoscopic oophorectomy there is risk of ovarian remnant due to improper tissue extraction or misapplication or improper use of pretied surgical loops, linear stapler, or bipolar electrodesiccation on the infundibulopelvic ligament, especially in women with a history of multiple pelvic surgeries, adhesions, or endometriosis.

Related Information: Ovarian remnant syndrome after laparoscopic oophorectomy

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Predictive Value of Magnetic Resonance Imaging in Differentiating Between Leiomyoma and Adenomyosis
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Predictive Value of Magnetic Resonance Imaging in Differentiating Between Leiomyoma and Adenomyosis

Abstract

Moghadam R, Lathi RB, Shahmohamady B, Saberi NS, Nezhat CH, Nezhat F, Nezhat C.
Center for Special Pelvic Surgery, 5555 Peachtree Dunwoody Road, Suite 276, Atlanta, GA 30342, USA.

Abstract

OBJECTIVE:
We evaluated the role of MRI as a preoperative diagnostic tool for leiomyoma and adenomyosis.

METHOD:
This is a retrospective chart review at a university-based hospital. The study included 1517 women who underwent hysterectomy or myomectomy over a 5-year period, and 153 women with a preoperative pelvic MRI were included. Comparisons were made between the results of the MRI and postoperative pathology reports.

RESULTS:
The MRI and pathology report were the same for 136 of 144 women with leiomyoma and 12 of 31 women with adenomyosis. The MRI had 94% sensitivity and 33% specificity for leiomyoma and 38% sensitivity and 91% specificity for adenomyosis. Positive and negative predictive values of MRI for leiomyoma were 95% and 27% with 90% accuracy. Positive and negative predictive values of MRI for adenomyosis were 52% and 85%, respectively, with 80% accuracy.

CONCLUSION:
MRI has a high sensitivity and a low specificity for diagnosing leiomyoma and a high specificity and a low sensitivity for diagnosing adenomyosis. Due to the high cost and technical variations, we suggest using MRI only as an adjunctive diagnostic tool when ultrasound is not conclusive and differentiation between the 2 pathologies ultimately affects patient management.

Related Information: Predictive Value of Magnetic Resonance Imaging in Differentiating Between Leiomyoma and Adenomyosis

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Pregnancy Following Laparoscopic Myomectomy: Preliminary Results.
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Pregnancy Following Laparoscopic Myomectomy: Preliminary Results.


Abstract

OBJECTIVE:
The objective of this study was to assess the outcome of pregnancy in a series of women who underwent laparoscopic myomectomy. A total of 115 women underwent laparoscopic myomectomy for pressure and pain (76.5%), abnormal bleeding (52.2%) and/or infertility (29.6%). Follow up data were obtained either by reviewing the patient’s chart or returned questionnaire. Of the 115 women, there were 42 pregnancies in 31 patients. Two women were lost to follow-up. Of the remaining 40 pregnancies, six ended with vaginal delivery at term. Caesareans were performed in 22 cases, including 21 at term and one at 26 weeks gestation. Two pregnancies were associated with a normal delivery, but the mode of delivery is unknown. Eight resulted in first trimester pregnancy loss, one was an ectopic pregnancy, and one patient underwent elective termination. Spontaneous uterine rupture was not noted during pregnancy or at term in any of the cases. Average length of follow-up from the date of surgery was 43 months, with a range of 9-99 months.

CONCLUSION:
Our series did not confirm the hypothesis that laparoscopic myomectomy is associated with an increased risk for uterine dehiscence during pregnancy. However, a larger series is needed to make a conclusive judgement.

Related Information: Pregnancy Following Laparoscopic Myomectomy: Preliminary Results.

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Preoperative periumbilical ultrasound-guided saline infusion (PUGSI) as a tool in predicting obliterating subumbilical adhesions in laparoscopy.
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Preoperative periumbilical ultrasound-guided saline infusion (PUGSI) as a tool in predicting obliterating subumbilical adhesions in laparoscopy.


Abstract

OBJECTIVE:
To report the novel technique of periumbilical ultrasound-guided saline infusion (PUGSI).

DESIGN:
Prospective study of two noninvasive diagnostic tests to detect obliterating subumbilical adhesions.

SETTING:
Tertiary care center.

PATIENT(S):
One hundred fifty patients were included in the study. Patients without risk factors for adhesions were used as a control group (n = 38), whereas the study group had risk factors for intra-abdominal adhesions (n = 112).

INTERVENTION(S):
Preoperative examination with the visceral slide and the PUGSI.

MAIN OUTCOME MEASURE(S):
The presence of obliterating subumbilical adhesions in the high-risk patient and the ability of the PUGSI to detect them preoperatively.

RESULT(S):
There were no obliterating umbilical adhesions in the control group. The prevalence of obliterating umbilical adhesions in the risk group was 3.6%. The visceral slide test had an accuracy of 96.4%, a sensitivity of 50%, and a specificity of 98.1%, with a negative predictive value of 98.1% and a positive predictive value of 50%. The PUGSI test was able to detect all cases of obliterating subumbilical adhesions, demonstrating sensitivity and specificity of 100%.

CONCLUSION(S):
The PUGSI test has excellent negative and positive predictive values and is useful in determining patients who have obliterating subumbilical adhesions. Use of both tests preoperatively appears to be helpful in identifying patients at risk for visceral injury during laparoscopic surgery.

Related Information: Preoperative periumbilical ultrasound-guided saline infusion (PUGSI) as a tool in predicting obliterating subumbilical adhesions in laparoscopy.

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Proposal of a Formal Gynecologic Endoscopy Curriculum
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Proposal of a Formal Gynecologic Endoscopy Curriculum

Morozov V, Nezhat C.
Center for Special Minimally Invasive Surgery and Reproductive Medicine, Atlanta, Georgia 30342, USA.

Abstract

As minimally invasive surgery becomes the standard of care in the United States and around the world, the formal training of endoscopic surgeons is an issue of growing concern. With the implementation of the American Association of Gynecologic Laparoscopists/Society of Reproductive Surgeons (AAGL/SRS)-sponsored fellowship training in gynecologic endoscopy and a growing number of hands-on courses, we have the challenge of credentialing and certifying future gynecologic endoscopists.

The objective of this article is to propose and to illustrate a uniform standardized core curriculum for obstetrics and gynecology residents, fellows in AAGL/SRS-sponsored fellowship programs, and participants in postgraduate courses. Consisting of 3 discrete parts, this proposal addresses formal laparoscopic training for gynecologists, already implemented and available to general surgeons, and a novel proposition for core training in hysteroscopy.

The curriculum is distributed in a quarterly system with specific educational objectives in each quarter. After quarters 1 and 2, an online examination is given; after quarter 3, participants are required to take and pass a hands-on examination at a specified testing facility; and at the end of quarter 4, participants must demonstrate leadership skills in the operating room and in a teaching capacity, and promote the principles of the AAGL.

Related Information: Proposal of a Formal Gynecologic Endoscopy Curriculum

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Proposed Classification of Hysterectomies Involving Laparoscopy
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Proposed Classification of Hysterectomies Involving Laparoscopy

Camran Nezhat, MD, Farr Nezhat, MD, Ceana Nezhat, MD, Dahlia Admon, MD, & A. Alex Nezhat, MD
J of the American Association of Gynecologic Laparoscopists, 8/95, Vol.2, No. 4

Abstract

A common terminology for the use of laparoscopy at hysterectomy is necessary so that collected data can be interpreted and conclusions applied. Many procedures are termed laparoscopic hysterectomy regardless of the extent to which laparoscopy is performed. We divided hysterectomy into seven steps and propose a common nomenclature based on the number of steps performed laparoscopically.

Recurrence Rate after Laparoscopic Myomectomy.
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Recurrence Rate after Laparoscopic Myomectomy.


Abstract

STUDY OBJECTIVE: To determine the recurrence rate of myomas after laparoscopic myomectomy.

DESIGN: Retrospective review (Canadian Task Force classification II-2).

SETTING: Tertiary referral center. PATIENTS: One hundred fourteen women (age 25-51 yrs, median 38 yrs) who were followed for an average of 37 months (range 6-120 mo).

INTERVENTION: Laparoscopic myomectomy.

MEASUREMENTS AND MAIN RESULTS: Follow-up data were obtained by chart review and from returned questionnaires. Variables were date of surgery, first diagnosis of recurrence, and last follow-up visit. There were 38 (33.3%) recurrences after an average interval of 27 months. Twenty-four of these women did not require treatment. Eight underwent a second laparoscopic myomectomy, and one had a third. One patient had myomectomy and then hysterectomy, and six patients chose hysterectomy to treat the first recurrence. Cumulative risk of recurrence (Kaplan-Meier curve) was 10.6% after 1 year, 31.7% after 3 years, and 51.4% after 5 years.

CONCLUSION: Although laparoscopic myomectomy is associated with less morbidity than removal by laparotomy, our results suggest that recurrence of myomas may be higher with the laparoscopic approach. Of 38 women with recurrent myoma, however, only 14 (36.8%) required additional surgery. Related Information: Recurrence Rate after Laparoscopic Myomectomy.

Related Information: Recurrence Rate after Laparoscopic Myomectomy.

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Reduced connexin 43 in eutopic endometrium and cultured endometrial stromal cells from subjects with endometriosis
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Reduced connexin 43 in eutopic endometrium and cultured endometrial stromal cells from subjects with endometriosis

Jie Yu, Ani Boicea, Kara Barrett, CO James, Indrani Bagchi, Milan Bagchi, Ceana Nezhat, Neil Sidell, Robert Taylor
Mol Hum Reprod. 2014 Mar;20(3):260-70.

Abstract

Abstract
Accumulating evidence indicates that reduced fecundity associated with endometriosis reflects a failure of embryonic receptivity. Microdomains composed of endometrial gap junctions, which facilitate cell-cell communication, may be implicated. Pharmacological or genetic inhibition of connexin (Cx) 43 block human endometrial cell differentiation in vitro and conditional uterine deletion of Cx43 alleles cause implantation failure in mice. The aim of this study was to determine whether women with endometriosis have reduced eutopic endometrial Cx43. Cx26 acted as a control. Endometrial biopsies were collected from age, race and cycle phase-matched women without (15 controls) or with histologically confirmed endometriosis (15 cases). Immunohistochemistry confirmed a predominant localization of Cx43 in the endometrial stroma, whereas Cx26 was confined to the epithelium. Cx43 immunostaining was reduced in eutopic biopsies of endometriosis subjects and western blotting of tissue lysates confirmed lower Cx43 levels in endometriosis cases, with Cx43/β-actin ratios=.4±1.5 in control and =1.2±0.3 in endometriosis biopsies (P<0.01). When endometrial stromal cells (ESC) were isolated from endometriosis cases, Cx43 levels and scrape loading-dye transfer were reduced by ∼45% compared with ESC from controls. In vitro decidualization of ESC derived from endometriosis versus control subjects resulted in lesser epithelioid transformation and a significantly reduced up-regulation of Cx43 protein (1.2±0.2- versus 1.7±0.4-fold, P<0.01). No changes in Cx26 were observed. While basal steady-state levels of Cx43 mRNA did not differ with respect to controls, ESC from endometriosis cases failed to manifest a response to hormone treatment in vitro. In summary, eutopic endometrial Cx43 concentrations in endometriosis cases were <50% those of controls in vivo and in vitro, functional gap junctions were reduced and hormone-induced Cx43 mRNA levels were blunted.

Retinoic acid biosynthesis is impaired in human and murine endometriosis.
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Retinoic acid biosynthesis is impaired in human and murine endometriosis.

Keely Pierzchalski, Robert Taylor, Ceana Nezhat, JW Jones, JL Napoli, G Yang, MA Kane, Neil Sidell
Biol Reprod. 2014 Oct;91(4):84.

Abstract

Abstract
Endometriosis is characterized by the presence of endometrial glands and stroma in extrauterine sites. Our objective was to determine whether endometriotic lesions (ELs) from women with endometriosis have altered retinoid levels compared with their eutopic endometrium, and to test the hypothesis that defects in all-trans retinoic acid (ATRA) biosynthesis in EL is related to reduced expression of cellular retinol-binding protein type 1 (RBP1). Retinoids were evaluated by liquid chromatography-tandem mass spectrometry and high-performance liquid chromatography in eutopic endometrial biopsies (EBs) and ELs from 42 patients with pathologically confirmed endometriosis. The ATRA levels were reduced, whereas the retinol and retinyl ester concentrations were elevated in EL compared with EB tissue. Similar results were found in a mouse model of endometriosis that used green fluorescent protein-positive endometrial tissue injected into the peritoneum of syngeneic hosts to mimic retrograde menses. The ATRA biosynthesis in vitro in retinol-treated primary human endometrial stromal cell (ESC) cultures derived from ELs was reduced compared with that of ESCs derived from patient-matched EBs. Correspondingly, RBP1 expression was reduced in tissue and ESCs derived from EL versus EB. Rbp1(-/-) mice showed reduced endometrial ATRA concentrations compared with wild type, associated with loss of tissue PUBLICATION and hypercellularity. These findings provide the first quantitative measurements of ATRA in human endometrium and endometriosis, demonstrating reduced ATRA in ectopic tissue and corresponding ESC cultures. Quantitation of retinoids in murine endometriosis and in Rbp1(-/-) mice supports the contention that impaired ATRA synthesis caused by reduced RBP1 promotes an “endometriosis phenotype” that enables cells to implant and grow at ectopic sites.

Robot-assisted laparoscopic presacral neurectomy: feasibility, techniques, and operative outcomes
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Robot-assisted laparoscopic presacral neurectomy: feasibility, techniques, and operative outcomes

Ceana Nezhat, Vadim Morozov
J Minim Invasive Gynecol. 2010 Jul-Aug;17(4):508-12.

Abstract

Abstract
STUDY OBJECTIVES: To report the feasibility and description of robot-assisted presacral neurectomy (RPSN) and to compare outcomes with laparoscopic presacral neurectomy (LPSN).
DESIGN: Prospective case series (Canadian Task Force classification III).
SETTING: Tertiary care center.
PATIENTS: Eighteen patients with central pelvic pain who underwent RPSN and 12 patients with central pelvic pain who underwent conventional LPSN in a metropolitan hospital between July 1, 2006, and April 30, 2008.
INTERVENTIONS: The da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) was used for the robotic portion of the procedure. Availability of the robot was the sole determining factor for the procedure chosen. Bipolar, monopolar, and ultrasonic instruments were used for conventional laparoscopy. All patients underwent several additional procedures performed laparoscopically including
adhesiolysis, treatment of endometriosis, appendectomy, enterolysis, and salpingo-ovariolysis.
MEASUREMENTS AND MAIN RESULTS: All presacral neurectomies in both groups were successfully completed by excising the hypogastric nervous plexus within the interiliac triangle. Presence of nerve ganglion and fibers was confirmed at pathologic analysis in all cases. Mean duration of presacral neurectomy, from incision of the posterior peritoneum at the sacral promontory to complete excision of the superior hypogastric nerve plexus at the interiliac triangle (Cotte triangle) was less than 10 minutes in both groups. Mean estimated blood loss was less than 30 mL for the entire surgical procedure (29.4 mL for RPSN, and 28.8 mL for LPSN). Median (range) patient age was 25 (19-44) years in the RPSN group, and 26 (18-36) years in the LPSN group; gravidity was 0, and parity was 0. All patients had central pelvic pain, the primary indication for presacral neurectomy. Concomitant indications for surgery included ovarian cysts, endometriosis, and adhesions. There were no intraoperative or postoperative complications. At analysis, follow-up ranged from 13 to 36 months. No short- or long-term complications related to the surgical procedure were reported. All patients reported subjective improvement of pelvic pain.
CONCLUSION: Robot-assisted laparoscopic presacral neurectomy is feasible and safe, without added risk of short- or long-term complications. It compares favorably to the conventional laparoscopic approach of presacral neurectomy. The surgical robot provides a better angle and 3-dimensional visualization of the operating field, similar to laparotomy, and supplemented with magnification. This combined with elimination of hand tremor enables better surgeon control.

Robot-Assisted Laparoscopic Surgery in Gynecology: Scientific Dream or Reality?
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Robot-Assisted Laparoscopic Surgery in Gynecology: Scientific Dream or Reality?

Abstract

Nezhat CR, Lavie O, Lemyre M, Unal E, Nezhat CH, Nezhat F.
Fertil Steril. 2009 Jun;91(6):2620-2.
Abstract

OBJECTIVE: To analyze the feasibility, safety, advantages, and disadvantages of using robotic technology for gynecologic surgeries in a large group of patients.

DESIGN: Retrospective study (Canadian Task Force classification II-3).

SETTING: Tertiary endoscopic referral centers. PATIENT(S): Eighty-seven patients requiring laparoscopic treatments for benign gynecologic conditions.

INTERVENTION(S): Charts reviewed from robotic-assisted gynecologic operative laparoscopies.

MAIN OUTCOME MEASURE(S): Length of surgery, time for robot assembly and disassembly, rate of conversion to laparotomies, and complications.

RESULT(S): Between January 2006 and August 2007, 137 robotically assisted gynecologic procedures were performed in 87 patients. The da Vinci Surgical System was used. The average length of the surgeries was 205 minutes (60-420 minutes). Assembly of the robot lasted 16 minutes (10-27 minutes) when disassembly took 2.5 minutes (2-6 minutes). There were no conversions to laparotomy. There were three complications.

CONCLUSION(S): Robotic-assisted technology, in its present state, is enabling more surgeons to perform endoscopic surgery. Its advantages are 3D Vision and a faster learning curve for suturing and operating while sitting. It’s an exciting enabling technology with a great future.

Related Information: Robot-Assisted Laparoscopic Surgery in Gynecology: Scientific Dream or Reality

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Robot-Assisted Laparoscopic Trachelectomy after Supracervical Hysterectomy
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Robot-Assisted Laparoscopic Trachelectomy after Supracervical Hysterectomy

Ceana Nezhat, Jocelyn Rogers
Fertil Steril. 2008 Sep;90(3):850.e1-3.

Abstract

OBJECTIVE: To present a case of successful robotic assisted laparoscopic trachelectomy.

DESIGN: Case report.

SETTING: Tertiary care facility.

PATIENT(S): A 40-year-old female with history of severe endometriosis and adhesions presented with persistent pain and bleeding after abdominal supracervical hysterectomy after failed attempt for laparoscopic-assisted vaginal hysterectomy and total abdominal hysterectomy.

INTERVENTION(S): Robot-assisted laparoscopic trachelectomy and treatment of associated pelvic disease.

MAIN OUTCOME MEASURE(S): Successful completion of robot-assisted trachelectomy.

RESULT(S): There were no intraoperative or postoperative complications and minimal blood loss. At 10 months’ follow-up the patient was doing well with resolution of her symptoms.

CONCLUSION(S): Robotic surgery may bridge the gap between laparotomy and laparoscopy for trachelectomy in complicated cases.

Related Information: Robot-Assisted Laparoscopic Trachelectomy after Supracervical Hysterectomy

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Robotic-Assisted Laparoscopic Partial Bladder Resection For The Treatment of Infiltrating Endometriosis
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Robotic-Assisted Laparoscopic Partial Bladder Resection For The Treatment of Infiltrating Endometriosis

Liu C, Perisic D, Samadi D, Nezhat F
J Minim Invasive Gynecol. 2008 Nov-Dec;15(6):745-8.

Abstract

Abstract
This article reveals our surgical approach for treatment of a patient with severe pelvic and infiltrative bladder endometriosis with mucosal involvement using robotic-assisted laparoscopic excision and cystotomy repair. To our knowledge, this is the first case of total robotic-assisted laparoscopic partial bladder resection for the treatment of endometriosis. This article also discusses the pros and cons of robotic-assisted surgery and the current literature on infiltrative bladder endometriosis.

Robotic versus standard laparoscopy for the treatment of endometriosis
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Robotic versus standard laparoscopy for the treatment of endometriosis

Camran Nezhat, Michael Lewis, S. Kotikela, A Veeraswamy,L Saadat, B Hajhosseini, Ceana Nezhat
Fertil Steril. 2010 Dec;94(7):2758-60.

Abstract

Abstract
OBJECTIVE: To compare robot assisted laparoscopic platform to standard laparoscopy for the treatment of endometriosis.
DESIGN: A retrospective cohort controlled study.
SETTING: Tertiary referral center.
PATIENT(S): Seventy-eight reproductive aged women.
INTERVENTION(S): Robot assisted or standard laparoscopy for the treatment of endometriosis between January 2008 and January 2009.
MAIN OUTCOME MEASURE(S): Operative time, estimated blood loss, hospitalization time, intraoperative and postoperative complications.
RESULT(S): Seventy-eight patients underwent treatment of endometriosis, 40 by robot assisted laparoscopy and 38 by standard laparoscopy. The two groups were matched for age, body mass index (BMI), stage of endometriosis, and previous abdominal surgery. Mean operative time with the robot was 191 minutes (range 135-295 minutes) compared with 159 minutes (range 85-320 minutes) during standard laparoscopy. There were no significant differences in blood loss, hospitalization, intraoperative or postoperative complications. There were no conversions to laparotomy.
CONCLUSION(S): Both robot assisted laparoscopic and standard laparoscopic treatment of endometriosis have excellent outcomes. The robotic technique required significantly longer surgical and anesthesia time, as well as larger trocars.

Role of Laparoscopic Surgery in Endometriosis Associated Infertility
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Role of Laparoscopic Surgery in Endometriosis Associated Infertility


Abstract

BACKGROUND: Endometriosis is a common disease of reproductive age group women. It was first described by Dr. Sampson in 1925 as, “presence of ectopic tissue which possesses the histological structure and function of uterine mucosa”. There is controversy surrounding its pathogenesis and the mechanism by which it causes infertility. Laparoscopic surgery is often used to treat this condition. Controversy exists as to the benefits of such surgery in infertile women.

OBJECTIVE: To explore whether laparoscopic surgery improves the chances of conception both by natural and assisted conception method in moderate to severe endometriosis. Methods: Retrospective review of English literature regarding role of laparoscopic surgery in managing endometriosis associated infertility using keywords – Endometriosis, Laparoscopy, Infertility, Pregnancy rate.

RESULTS: A large prospective study by Adamson et al 1993 showed that laparoscopic surgery significantly increased the cumulative pregnancy rate which was confirmed by a further meta-analysis in 1994. A large retrospective analysis by Osuga et al 1997 reported that pregnancy rate is unrelated to the stage of endometriosis. Further studies in 2002 suggested that the laparoscopic surgery increases the pregnancy rates in the first 6-12 months post operation. Two randomized controlled trials demonstrated higher pregnancy rates after laparoscopic excision of endometriomata. Few studies showed the benefits of laparoscopic endometrioma excision before IVF like reduced oocyte retrieval risks, missing occult malignancy and worsening of endometriosis during ovulation stimulation overweighs the drawback of cost and surgical risk. In addition, studies have reported improvement of dyspareunia after laparoscopic debulking for rectovaginal endometriosis.

CONCLUSION: There are no large prospective randomized double blind controlled trials available to date in this area. In spite of heterogenicity among the available studies, current evidence suggests that laparoscopic excision or ablation, either by electrocautery or laser is beneficial in improving pregnancy rates, both by natural and assisted.

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Safe laser endoscopic excision or vaporization of peritoneal endometriosis
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Safe laser endoscopic excision or vaporization of peritoneal endometriosis

Nezhat C, Nezhat FR.
Fertility and Endocrinology Center, Atlanta, Georgia 30342.

Abstract

In using laser laparoscopy for the treatment of endometriosis, protecting patients from inadvertent injury to pelvic structures adjacent to diseased tissue has been a major concern. In many cases, because of this risk, surgeons have stopped short of effecting thorough treatment of endometrial implants on the bowel, bladder, ureters, or great vessels. In a large series of patients, we have used hydrodissection successfully with few complications. We believe that the technique of hydrodissection is a safe and efficient method, permitting more thorough treatment of endometriosis that otherwise might be deemed untreatable by laser laparoscopy.
PMID: 2526028 [PubMed – indexed for MEDLINE]
Related Information: Safe laser endoscopic excision or vaporization of peritoneal endometriosis

Salpingectomy Via Laparoscopy: A New Surgical Approach
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Salpingectomy Via Laparoscopy: A New Surgical Approach

Farr Nezhat, MD, Wendy Winer, RN, BSN, & Camran Nezhat, MD
Journal of Laparoendoscopic Surgery, Vol. 1, No.2, 1991

Abstract

This study presents 100 consecutive cases of total salpingectomy performed via laparoscopy for indications of ruptured or recurrent ectopic pregnancy, hydrosalpinges, torsion of the fallopian tube, hematosalpinges or extensive adhesions. A multiple abdominal puncture approach was used, and salpingectomy was accomplished by electrosurgical coagulation and laser transection of the isthmus, mesosalpinx, and tubo-ovarian ligaments using the CO2 laser. The fallopian tubes were removed from the pelvic cavity through one of the suprapubic punctures. The mean duration of the procedure was 22 minutes, and the mean duration of hospitalization after surgery 7.4 hours. No major intraoperative or postoperative complications were encountered. Laparoscopic salpingectomy appears to be a safe and relatively simple procedure associated with the advantages of outpatient surgery.

Severe Endometriosis and Operative Laparoscopy.
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Severe Endometriosis and Operative Laparoscopy.

Nezhat C, Nezhat F, Nezhat CH, Seidman DS.
Department of Surgery, Stanford University School of Medicine, California, USA.

Abstract

Laparoscopic surgery offers the most effective form of treatment for women with severe endometriosis. The development of advanced laparoscopic techniques allows complete removal of deeply infiltrating lesions. Implants can be laparoscopically dissected from all anatomical locations, including severe involvement of the ureter, bladder, and colon. When the endometriosis penetrates through the entire depth of the organ wall, complete resection and reanastomosis of the ureter or bowel can be safely performed laparoscopically by the experienced surgeon. However, optimal laparoscopic treatment requires not only surgical skill, but also comprehensive knowledge of pelvic anatomy and a good understanding of endometriosis and its progression.
PMID: 7578971 [PubMed – indexed for MEDLINE]
Related Information: Severe Endometriosis and Operative Laparoscopy.

Smoke from laser surgery: is there a health hazard
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Smoke from laser surgery: is there a health hazard

Nezhat C, Winer WK, Nezhat F, Nezhat C, Forrest D, Reeves WG.
Fertility and Endocrinology Center, Atlanta, GA.

Abstract

The composition of plume produced during carbon dioxide laser endoscopic treatment for endometriosis was examined to determine whether it represented a hazard to the surgical staff. A total of 32 plume samples were collected from 17 women undergoing laser laparoscopic treatment for endometriosis and/or adhesions. The smoke was found to consist of particles having a median aerodynamic diameter of 0.31 micron with a range of 0.10-0.80 micron. The size range has two consequences: 1) using a human red blood cell as a model for all cells, it can be stated with greater than 99.9999% certainty that no cell-size particles, including cancer cells, are present in the plume; 2) particles in this size range are too small to be effectively filtered by currently available surgical masks.
PMID: 3683071 [PubMed – indexed for MEDLINE]
Related Information: Smoke from laser surgery: is there a health hazard

Stage I Ovarian Carcinoma: Different Clinical Pathologic Patterns
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Stage I Ovarian Carcinoma: Different Clinical Pathologic Patterns

Deligdisch L, Pénault-Llorca F, Schlosshauer P, Altchek A, Peiretti M, Nezhat F
Fertil Steril. 2007 Oct;88(4):906-10

Abstract

OBJECTIVE: To analyze clinicopathologic patterns of early ovarian carcinoma.

DESIGN: Retrospective chart and histopathology review.

SETTING: Mount Sinai School of Medicine, New York and the Centre Jean Perrin, Clermont Ferrand, France.

PATIENT(S): Seventy-six consecutive cases of Fédération Internationale de Gynécologie et d’Obstétrique stage I ovarian carcinoma.

INTERVENTION(S): Surgical staging.

MAIN OUTCOME MEASURE(S): Symptomatology, pathology, and histology analysis.

RESULT(S): Twenty-two cases (29%) were serous papillary carcinomas and 54 were nonserous carcinomas (71%) (40 endometrioid, 10 clear cell, and 4 mixed endometrioid and clear cell carcinomas). Ninety-eight percent of ovarian endometriosis, 95% of endometrial carcinomas, and 83% of endometrial polyps and hyperplasias were associated with nonserous carcinomas. Most patients with serous papillary carcinoma presented with asymptomatic pelvic masses; patients with nonserous carcinomas presented with pelvic pain or abnormal vaginal bleeding with or without pelvic mass.

CONCLUSION(S): Over two thirds of stage I ovarian carcinomas were nonserous, and were diagnosed because of associated symptoms: pelvic pain with endometriosis and/or adnexal masses, or vaginal bleeding from endometrial pathology. Serous papillary carcinomas were often asymptomatic and diagnosed during follow-up evaluations in breast cancer patients. Stage I ovarian carcinoma has different clinical and pathologic patterns than advanced ovarian carcinoma. The risk of ovarian and endometrial malignancy should be taken into consideration during evaluation of patients with endometriosis and breast cancer histories.

Surgery for Endometriosis
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Surgery for Endometriosis

Camran Nezhat, MD, Sheryl Silfen, MD, Farr Nezhat, MD, & Dan Martin, MD
Obstetrics & Gynecology, 1991, 3:385-393

Abstract

Advanced operative laparoscopy in general, and videolaseroscopy using CO2 laser via operative channel of the laparoscope and video, specifically, has revolutionized the management of endometriosis. Adhesion formation is reduced and subsequent fertility rates exceed those obtained with laparotomy. The most complicated cases of endometriosis, including involvement of the rectovaginal septum, gastrointestine, and urinary tract, can now be treated endoscopically by an experienced operative laparoscopist.

Surgical treatment of endometriosis via laser laparoscopy
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Surgical treatment of endometriosis via laser laparoscopy

Nezhat C, Crowgey SR, Garrison CP.
Fertil Steril. 1986 Jun;45(6):778-83.

Abstract

The carbon dioxide laser has been used laparoscopically for the removal of endometriotic implants, excision of endometrioma capsules, and lysis of adnexal adhesions in 102 patients. These patients were followed for a period ranging from 12 to 18 months, during which time there were 62 pregnancies, including 9 spontaneous abortions and 1 elective termination. The rates of conception after surgery were as follows: 75% for patients with mild endometriosis, 62% for patients with moderate endometriosis, 42.1% for patients with severe endometriosis, and 50% for patients with extensive endometriosis. Of 102 patients presenting with infertility attributed to endometriosis, 60.7% conceived within 24 months after laser laparoscopy. In this patient group, no immediate or subsequent laparotomy was required before conception was achieved, nor was hormonal therapy enacted during the study period after surgery.
PMID: 2940121 [PubMed – indexed for MEDLINE]
Related Information: Surgical treatment of endometriosis via laser laparoscopy

Surgical treatment of endometriosis via laser laparoscopy and videolaseroscopy
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Surgical treatment of endometriosis via laser laparoscopy and videolaseroscopy

Nezhat C, Crowgey SR, Garrison CP.
Fertil Steril. 1986 Jun;45(6):778-83.

Abstract

The carbon dioxide laser has been used laparoscopically for the removal of endometriotic implants, excision of endometrioma capsules, and lysis of adnexal adhesions in 102 patients. These patients were followed for a period ranging from 12 to 18 months, during which time there were 62 pregnancies, including 9 spontaneous abortions and 1 elective termination. The rates of conception after surgery were as follows: 75% for patients with mild endometriosis, 62% for patients with moderate endometriosis, 42.1% for patients with severe endometriosis, and 50% for patients with extensive endometriosis. Of 102 patients presenting with infertility attributed to endometriosis, 60.7% conceived within 24 months after laser laparoscopy. In this patient group, no immediate or subsequent laparotomy was required before conception was achieved, nor was hormonal therapy enacted during the study period after surgery.
PMID: 2940121 [PubMed – indexed for MEDLINE]
Related Information: Surgical treatment of endometriosis via laser laparoscopy

Synchronous Rectovaginal, Urinary Bladder and Pulmonary Endometriosis
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Synchronous Rectovaginal, Urinary Bladder and Pulmonary Endometriosis

Hilaris GE, Payne CK, Osias J, Cannon W, Nezhat CR
JSLS. 2005 Jan-Mar;9(1):78-82

Abstract

BACKGROUND: Extragenital endometriosis is an uncommon condition that can affect almost any organ system and tissue in the human body. Disease involving multiple distant sites is extremely uncommon.

METHODS: We report a rare case of synchronous rectovaginal, urinary bladder, and pulmonary endometriosis. We performed a Medline literature search using keywords “endom etriosis,” “recto vaginal,” “pulmonary,” “bladder,” “ureteral,” “bowel,” “extrapelvic,” and “extragenital” and were unable to find any prior case reports of such findings. A 31-year-old female presented with catamenial dysuria of 1-year duration, pleurisy associated with spontaneous pneumothoraces of 7 months’ duration and a long-standing history of pelvic pain. A multispecialty team with experience in endoscopic techniques was assembled, consisting of a thoracic, a urologic, and a gynecologic surgeon. Video-assisted thoracoscopic surgery with fulguration of all visible pleural endometriosis and pleurodesis was performed, followed by laparoscopic segmental bladder wall endometrioma excision and resection of rectovaginal endometriosis. Twelve months after surgery and without additional hormonal treatment, the patient is symptom free.

CONCLUSION: Extragenital endometriosis may coexist in multiple sites. A high index of suspicion aids in the diagnosis. A multidisciplinary approach in a tertiary center, followed by appropriate surgical eradication of visible disease, can successfully treat endometriosis even in such extreme cases.

The Dilemma of Endometriosis: Is consensus possible with an enigma?
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The Dilemma of Endometriosis: Is consensus possible with an enigma?

Nezhat C, Littman ED, Lathi RB, Berker B, Westphal LM, Giudice LC, Milki AA
Fertil Steril. 2005 Dec;84(6):1587-8

Abstract

Many will agree that the use of laparoscopy to diagnose and potientially treat endometriosis in patients who suffer from infertility has been superseded by IVF and sometimes oocyte donation, especially in older patients. The findings of our study add another dimension to management of endometriosis in the setting of infertility and emphasize the importance of keeping laparoscopy in the infertility management equation.

The Direct Trocar Technique: An Alternative Approach to Abdominal Entry for Laparoscopy
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The Direct Trocar Technique: An Alternative Approach to Abdominal Entry for Laparoscopy

Abstract

Jacobson MT, Osias J, Bizhang R, Tsang M, Lata S, Helmy M, Nezhat C, Nezhat C.
Department of Ob/Gyn, Stanford University School of Medicine, California, USA.
Abstract

OBJECTIVE: The direct trocar technique is an alternative to Veress needle insertion and open laparoscopy for accessing the abdominal cavity for operative laparoscopy. We review our approach to abdominal entry in 1385 laparoscopies performed between September 1993 and June 2000 by our group at Stanford University Hospital, a tertiary Medical Center.

METHODS: We performed a retrospective chart review of 1385 patients who underwent operative laparoscopy during the study years. The mode of abdominal entry, patient demographics, and complications were reviewed.

RESULTS: The transumbilical direct trocar entry method was used in 1223 patients. In 133 patients, the Veress needle insertion technique was used. Open laparoscopy was used in 22 patients. Three (0.21%) major complicadons occurred: 1 enterotomy, 1 omental herniation, and 1 bowel hemiation. One complication was related to primary access (0.072%) in a patient who had an open laparoscopy. She sustained an enterotomy during placement of the primary trocar. The bowel was repaired laparoscopically. No trocar-related injuries occurred among the 1223 patients in whom the direct trocar entry technique was used. One patient had an omental herniation and required a repeat laparoscopy on postoperative day 2. The second patient had a repeat laparoscopy on the 12th postoperative day to repair a bowel herniation. None of our patients required a laparotomy. No vascular injuries occurred.

CONCLUSION: Based on our experience, the direct trocar technique is a safe approach to abdominal entry for laparoscopic surgery.

Related Information: The Direct Trocar Technique: An Alternative Approach to Abdominal Entry for Laparoscopy

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The Incidence of Adhesions After Prior Laparotomy: A Laparoscopic Appraisal
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The Incidence of Adhesions After Prior Laparotomy: A Laparoscopic Appraisal

Abstract



Abstract

OBJECTIVE: To relate the presence of intra-abdominal adhesions after laparotomy to the site of incision, repeat laparotomy, and the clinical indication for prior surgery.

METHODS: Three hundred sixty women undergoing operative laparoscopy after a previous laparotomy were assessed for adhesions between the abdominal wall and the underlying omentum and bowel. Complications resulting directly from these adhesions were documented.

RESULTS: Patients with prior midline incisions had significantly more adhesions (58 of 102) than those with Pfannenstiel incisions (70 of 258). Patients with midline incisions performed for gynecologic indications had significantly more adhesions (109 of 259) than all types of incisions performed for obstetric indications (12 of 55). The presence of adhesions in patients with previous obstetric surgery was not affected by the type of incision. Adhesions to the bowel were significantly more frequent after midline incisions above the umbilicus. Twenty-one women suffered direct injury to adherent omentum and bowel during the laparoscopic procedure.

CONCLUSIONS: Intra-abdominal adhesions between the abdominal scar and underlying viscera are a common consequence of laparotomy. Patients undergoing laparoscopy after a previous laparotomy should be considered at risk for the presence of adhesions between the old scar and the bowel and omentum.

Related Information: The Incidence of Adhesions After Prior Laparotomy: A Laparoscopic Appraisal

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The Incidence of Endometriosis in Posthysterectomy Women
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The Incidence of Endometriosis in Posthysterectomy Women

Nezhat FR, Admon D, Seidman D, Nezhat CH, Nezhat C.
Center for Special Pelvic Surgery, 5555 Peachtree-Dunwoody Road, Suite 276, Atlanta, GA 30342.

Abstract

One hundred consecutive patients, age 24-62, status post total hysterectomy with and without bilateral oophorectomy (BSO), presented with chronic pelvic pain. All underwent laparoscopy. Of those who did not have BSO, 30 had definite endometriosis found at laparoscopy and five had questionable endometriosis. Of the 30 patients found to have definite endometriosis, 24 had a positive history of endometriosis, five had a negative history and one had a questionable history. Sixty-four underwent total hysterectomy with BSO. Of these 64, definite endometriosis was found in 22 at laparoscopy, questionable endometriosis was noted in 3, and findings for 39 were negative. Of the 22 women with positive endometriosis, 19 had a positive history of endometriosis, 2 had a negative history and 1 had a questionable history. Of these 22 patients, 13 were on estrogen replacement therapy, 2 were on estrogen and progesterone, 2 were on testosterone estradiol pellets, 2 were on GnRH analogs, 1 was on danazol and 2 received no medication. In this group, the time between hysterectomy and our laparoscopy was eight months to 15 years. Twenty-four of the 100 patients had a positive history of endometriosis with negative findings at laparoscopy. Our findings support the view that endometriosis will be found at laparoscopy in a significant number of women with chronic pelvic pain status post hysterectomy with or without BSO, especially if the woman has a positive history of endometriosis.
PMID: 9073727 [PubMed – as supplied by publisher]
Related Information: The Incidence of Endometriosis in Posthysterectomy Women

The Relationship of Endometriosis and Ovarian Malignancy: A Review
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The Relationship of Endometriosis and Ovarian Malignancy: A Review

Abstract

Nezhat F, Datta MS, Hanson V, Pejovic T, Nezhat C, Nezhat C.
Department of Obstetrics, Mount Sinai Medical Center, New York, New York 10019, USA.
Abstract

OBJECTIVE: To review the malignant potential of endometriosis based on epidemiologic, histopathologic, and molecular data.

DESIGN: Literature review.

RESULT(S): The pathogenesis of endometriosis remains unclear. The histopathologic development of endometriosis has undergone long-term investigation. Studies have confirmed histologic transition from benign endometriosis to ovarian malignancy, including malignant transformation of extraovarian endometriosis. The prevalence of endometriosis in patients with epithelial ovarian cancer, especially in endometrioid and clear cell types, has been confirmed to be higher than in the general population. Ovarian cancers and adjacent endometriotic lesions have shown common genetic alterations, such as PTEN, p53, and bcl gene mutations, suggesting a possible malignant genetic transition spectrum. Furthermore, endometriosis has been associated with a chronic inflammatory state leading to cytokine release. These cytokines act in a complex system in which they induce or repress their own synthesis and can cause unregulated mitotic division, growth and differentiation, and migration or apoptosis similar to malignant mechanisms.

CONCLUSION(S): The malignant potential of endometriosis holds serious implications for management, such as the need for earlier and more meticulous surgical intervention for complete disease treatment.

Related Information: The Relationship of Endometriosis and Ovarian Malignancy: A Review

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The Risk of Carbon Monoxide Poisoning After Prolonged Laparoscopic Surgery
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The Risk of Carbon Monoxide Poisoning After Prolonged Laparoscopic Surgery

Abstract

Nezhat C, Seidman DS, Vreman HJ, Stevenson DK, Nezhat F, Nezhat C.
Department of Gynecology and Obstetrics, Stanford University School of Medicine, California, USA.
Abstract

OBJECTIVE: To evaluate whether thermal energy produced by laser and bipolar electrosurgery during laparoscopic procedures significantly elevates blood carboxyhemoglobin levels.

METHODS: We prospectively studied 27 healthy nonsmoking patients, mean +/- standard deviation (SD) age 39.1 +/- 8.0 years (range 22-56), scheduled for laparoscopic procedures in which smoke was generated. Prolonged operative laparoscopy involved high-flow carbon dioxide insufflation, intensive evacuation of intra-abdominal smoke, and controlled hyperventilation with 50-100% oxygen. Laser and bipolar electrosurgery were used in all cases. Blood samples were drawn before and after surgery. Carboxyhemoglobin concentrations were measured using a highly accurate gas chromatography method.

RESULTS: The mean +/- SD duration of surgery was 141 +/- 72 minutes (range 45-300). The mean +/- SD carboxyhemoglobin levels were 0.70 +/- 0.15% (range 0.44-1.20%) before surgery and 0.58 +/- 0.20% (range 0.30-1.33%) after surgery. A significant decrease (P < .001) in carboxyhemoglobin concentrations occurred during surgery (mean +/- SD, 20 +/- 11%; range 3-46%). The carboxyhemoglobin level was increased at the end of surgery in only one woman. In only one patient did the levels exceed 1% (1.33%), still well below the human threshold tolerance level of 2%. The Spearman correlation coefficient between carboxyhemoglobin concentrations and duration of surgery was r = 0.308 (P = .12).

CONCLUSION: Carbon monoxide (CO) poisoning is not associated with even prolonged laparoscopic surgical procedures. This may be attributed to aggressive smoke evacuation that minimizes exposure to CO, and to active elimination of CO by ventilation with high oxygen concentrations.

Related Information: The Risk of Carbon Monoxide Poisoning After Prolonged Laparoscopic Surgery

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The Role of Intraoperative Proctosigmoidoscopy in Laparoscopic Pelvic Surgery
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The Role of Intraoperative Proctosigmoidoscopy in Laparoscopic Pelvic Surgery

Nezhat C, Seidman D, Nezhat F, Nezhat C.
Center for Special Pelvic Surgery, Atlanta, Georgia, USA.

Abstract

STUDY OBJECTIVE: To report the outcome of rigid sigmoidoscopy during operative laparoscopy in patients at high risk for rectosigmoid and large bowel injury.

DESIGN: Prospective patient database with retrospective chart review (Canadian Task Force classification II-3).

SETTING: Referral practice and tertiary medical center.

PATIENTS: Two hundred sixty-two women with rectosigmoid endometriosis and adhesions.

INTERVENTIONS: Rigid sigmoidoscopy during laparoscopy. At the end of surgery, proctosigmoidoscopy was performed to evaluate intraluminal abnormality or rectosigmoid injury. The pelvis was then filled with isotonic fluid to observe laparoscopically for air leakage.

MEASUREMENTS AND MAIN RESULTS: Sigmoidoscopy was performed due to a lesion involving the rectum or sigmoid in 60.7%, large bowel in 11.1%, and posterior cul-de-sac in 28.2% of patients. During laparoscopy, endometriosis was found in 30.5%, adhesions in 20.2%, and both in 43.5%. Four women (1.5%) had bowel injury identified during sigmoidoscopy; all bowel injuries were treated by intracorporeal laparoscopic suturing. One incomplete repair was detected by sigmoidoscopy. In one woman (0.4%) a rectal polyp was detected.

CONCLUSION: Bowel injury is one of the most serious complications of laparoscopy. Early detection and prompt intraoperative management are essential to prevent a potentially catastrophic outcome. Sigmoidoscopy is a relatively easy procedure and aids during laparoscopy in the diagnosis of bowel perforation and in assessment of bowel wall invasion and potential stricture caused by endometriosis. It is a safe procedure even when performed immediately after extensive laparoscopic surgical treatment of rectosigmoid endometriosis and adhesions.

Related Information: The Role of Intraoperative Proctosigmoidoscopy in Laparoscopic Pelvic Surgery

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The Role of Laparoscopic: Assisted Myomectomy (LAM)
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The Role of Laparoscopic: Assisted Myomectomy (LAM)


Abstract

Laparoscopic myomectomy has recently gained wide acceptance. However, this procedure remains technically highly demanding and concerns have been raised regarding the prolonged time of anesthesia, increased blood loss, and possibly a higher risk of postoperative adhesion formation. Laparoscopic-assisted myomectomy (LAM) is advocated as a technique that may lessen these concerns regarding laparoscopic myomectomy while retaining the benefits of laparoscopic surgery, namely, short hospital stay, lower costs, and rapid recovery. By decreasing the technical demands, and thereby the operative time, LAM may be more widely offered to patients. In carefully selected cases, LAM is a safe and efficient alternative to both laparoscopic myomectomy and myomectomy by laparotomy. These cases include patients with numerous large or deep intramural myomas. LAM allows easier repair of the uterus and rapid morcellation of the myomas. In women who desire a future pregnancy, LAM may be a better approach because it allows meticulous suturing of the uterine defect in layers and thereby eliminates excessive electrocoagulation.

Related Information: The Role of Laparoscopic: Assisted Myomectomy (LAM)

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The Role of Laparoscopy in the Management of Gynecologic Malignancy
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The Role of Laparoscopy in the Management of Gynecologic Malignancy

Camran Nezhat, MD, Farr Nezhat, MD, Ceana H. Nezhat, MD, Matthew O. Burrell, MD, Benedict B. Benigno, MD & Carlos Ramirez, MD
Seminars in Surgical Oncology 10:431-439 (1994)

Abstract

With the advent of minimally invasive laparoscopic techniques, most gynecologic procedures for benign conditions can be performed in an outpatient setting. However, the role of such techniques in gynecologic oncology is not well defined. By reviewing the literature and presenting some new data, we attempt to elucidate the applications of operative videolaparoscopy in gynecologic oncology. Advanced laparoscopic techniques are utilized for the management of cervical cancer as well as the staging and treatment of endometrial and ovarian cancers. Such techniques are used in performing radical hysterectomy for early stage cervical cancer, pelvic and paraaortic lymphadenectomy, and second look laparoscopy following chemotherapy for ovarian cancer. Even though preliminary data are encouraging, large prospective controlled studies with long-term follow-up are necessary to better define the role and limitations of laparoscopy in the treatment of gynecologic malignancies.

Total Laparoscopic Radical Hysterectomy and Pelvic Lymphadenectomy Using Harmonic Shears
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Total Laparoscopic Radical Hysterectomy and Pelvic Lymphadenectomy Using Harmonic Shears

Nezhat F, Mahdavi A, Nagarsheth NP
J Minim Invasive Gynecol. 2006 Jan-Feb;13(1):20-5

Abstract

STUDY OBJECTIVE: To describe the feasibility and outcome of total laparoscopic radical hysterectomy with or without pelvic lymphadenectomy for patients with stage I cervical cancer or severe pelvic endometriosis using harmonic shears as the sole instrument for dissection, division, and maintenance of hemostasis of all major surgical pedicles.

DESIGN: Retrospective review (Canadian Task Force classification II-2).

SETTING: University hospital and affiliate institutions.

PATIENTS: Seven patients who underwent total laparoscopic radical hysterectomy using harmonic shears for International Federation of Gynecology and Obstetrics stage IA2 to IB1 cervical cancer and pelvic endometriosis at our institution or affiliate hospital from January 2004 through February 2005.

INTERVENTION: A retrospective review of patients that underwent total laparoscopic radical hysterectomy with or without pelvic lymphadenectomy at our institution using harmonic shears was performed. Information regarding preoperative, intraoperative, and postoperative events was recorded and analyzed.

MEASUREMENTS AND MAIN RESULTS: Pelvic lymphadenectomy was performed in all cancer cases. Mean patient age was 40 years (range 30-53 years). Mean estimated blood loss was 143 mL (range 100-200 mL). Mean operating time was 293 minutes (range 255-385 minutes). Mean pelvic node count was 27.8 (range 24-34) for cancer cases. Mean hospital stay was 3.2 days (range 2-7 days). One patient developed a vaginal cuff abscess postoperatively that was managed conservatively with drainage in the office setting followed by intravenous antibiotics. Another patient developed urinary retention for 2 weeks after surgery. There were no other intraoperative or postoperative complications.

CONCLUSION: Total laparoscopic radical hysterectomy with pelvic lymphadenectomy using harmonic shears is a technically feasible and safe procedure. Larger studies and long-term follow-up are required to determine the oncologic outcomes of these patients.

Traumatic hypogastric artery bleeding controlled with bipolar desiccation during operative laparoscopy
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Traumatic hypogastric artery bleeding controlled with bipolar desiccation during operative laparoscopy

Nezhat F, Brill A, Nezhat C.
Stanford University Medical School, 300 Pasteur Drive, Stanford, CA 94305, USA.

Abstract

During multipuncture operative laparoscopy to excise peritoneal endometriosis involving the pelvic sidewall near the origin of the uterine artery, the lower portion of the hypogastric artery was perforated. The acute hemorrhage was controlled by immediately grasping the lacerated blood vessel with a 5-mm atraumatic grasping forceps. A Kleppinger bipolar forceps set at 25 W desiccated and sealed the artery successfully. As no further bleeding was noted, the procedure was terminated. The patient remained overnight for observation, and was discharged from the hospital the next day. She is doing well 18 months after the injury and repair.
PMID: 9050483 [PubMed – indexed for MEDLINE]
Related Information: Traumatic hypogastric artery bleeding controlled with bipolar desiccation during operative laparoscopy

Tubal factor infertility: diagnosis and management in the era of assisted reproductive technology
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Tubal factor infertility: diagnosis and management in the era of assisted reproductive technology

Erica Dun, Ceana Nezhat
Obstet Gynecol Clin North Am. 2012 Dec;39(4):551-66.

Abstract

Tubal factor infertility accounts for a large portion of female factor infertility. The most prevalent cause of tubal factor infertility is pelvic inflammatory disease and acute salpingitis. The diagnosis of tubal occlusion can be established by a combination of clinical suspicion based on patient history and diagnostic tests, such as hysterosalpingogram, sonohysterosalpingography, and laparoscopy with chromopertubation. Depending on several patient factors, tubal microsurgery or more commonly in vitro fertilization with its improving success rates are the recommended treatment options.

Update on the Male and Female Climacteric
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Update on the Male and Female Climacteric

R.B. Greenblatt, MD, C. Nezhat, MD, R. A. Roesel, PhD, and P.K. Natrajan, MD
J American Geriatrics Society, Vol XXVII 11/79 Number 11

Abstract

The gonadal steroids – estrogens and androgens – appear to have a mood-elevating, psychotonic effect. The improved sense of well-being and increased vigor probably is engendered by restoration of somatic efficiency and psychic equilibrium. 1. The male climacteric, as observed in a limited number of men, is associated with a low level of serum testosterone. The levels of follicle-stimulating hormone and luteinizing hormone are not elevated because estrogen concentration continues unaltered well into old age. Androgen replacement therapy often lessens fatigue, depression and headaches, and improves libidinous drives. 2. In the aging female, many climacteric symptoms other than those due to vasomotor instability were heretofore considered merely coincidental. Recent studies suggest that the metabolism of cerebral hormones is markedly influenced by endogenous and exogenous gonadal steroids. Thus, postmenopausal depression, headaches, and nervousness may be hormone-dependent symptoms. 3. The incidence of endometrial cancer is no greater and is probably less in estrogen-treated women than in women not treated with estrogen, if regular cyclic courses of an oral progestogen are added to the regimen.

Urinary Tract Endometriosis Treated by Laparoscopy
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Urinary Tract Endometriosis Treated by Laparoscopy

Nezhat C, Nezhat F, Nezhat CH, Nasserbakht F, Rosati M, Seidman DS
Fertil Steril. 1996 Dec;66(6):920-4

Abstract

OBJECTIVE: To evaluate the efficacy of the laparoscopic approach for the diagnosis and treatment of severe urinary tract endometriosis. DESIGN: Retrospective review of 28 cases of severe urinary tract endometriosis. SETTING: Center for Special Pelvic Surgery, a tertiary referral center. PATIENT(s): Between October 1989 and September 1994, we treated 28 women who had deeply infiltrating urinary tract endometriosis (bladder, 7, ureter, 21). INTERVENTION(s): All procedures were performed laparoscopically. MAIN OUTCOME MEASURE(s): Postoperative urinary function, pain relief, and complications. RESULT(s): Those who had vesical endometriosis underwent partial cystectomy and primary repair. Partial ureteral obstruction was found in 17 women; 10 underwent ureterolysis and excision of endometriosis, and 7 had partial wall resection. Four patients with ureter involvement had complete obstruction. Three underwent partial resection and ureteroureterostomy, and one had ureteroneocystostomy. The rate of ureteral endometriosis in the present series is higher than that reported previously. CONCLUSION(s): Severe infiltrative endometriosis of the bladder and the ureter can present without specific symptoms and can cause silent compromise of renal function. We demonstrated that the laparoscopic approach is safe and effective in the diagnosis and treatment of this entity.

Use of hysteroscopy in addition to laparoscopy for evaluating chronic pelvic pain.
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Use of hysteroscopy in addition to laparoscopy for evaluating chronic pelvic pain.

Nezhat F, Nezhat C, Nezhat CH, Levy JS, Smith E, Katz L.
Department of Obstetrics and Gynecology, Mercer University School of Medicine, Macon, Georgia, USA.

Abstract

This study assessed whether hysteroscopy can provide information concerning the cause of chronic pelvic pain. We prospectively evaluated the findings in 547 consecutive patients who had laparoscopy to evaluate chronic pelvic pain at a large, referral-based clinic and outpatient suite of a suburban hospital. Forty-eight had previous hysterectomies. The remaining 499 had hysteroscopy during the same surgery and met the following qualifications: chronic pelvic pain, dysmenorrhea, dyspareunia, dysuria, back pain, pelvic pressure or dyschezia for a duration greater than six months and previous failed medical therapy. When endometriosis was the primary diagnosis at laparoscopy, hysteroscopy revealed abnormalities in 62 (32.5%) of 191 patients. At hysteroscopy, 46 of 105 patients (43.8%) with single or multiple leiomyomas of significant sizes diagnosed laparoscopically were noted to have pathology within the uterine cavity. Ten of 11 patients (90.9%) found to have ovarian cysts underwent hysteroscopy. Four (40%) had uterine abnormalities; the most common was cervical stenosis. Pelvic adhesions were found in 118 patients (21.6%). Eighty-nine underwent hysteroscopy, and 24 (27%) had intrauterine abnormalities. Ninety-six patients (17.5%) who underwent laparoscopic evaluation had endometriosis and pelvic adhesions. Ninety-three of these underwent hysteroscopy, and abnormalities were noted in 26 (28.0%). In eight women (1.5%) no abnormality was found at laparoscopy. Two underwent hysteroscopy, and no abnormality was noted in either woman. Hysteroscopy provides useful, adjunctive information and may improve the diagnosis and treatment of chronic pelvic pain.
PMID: 7650654 [PubMed – indexed for MEDLINE]
Related Information: Use of hysteroscopy in addition to laparoscopy for evaluating chronic pelvic pain.

Use of Laparoscopic Ultrasonography to Detect Ovarian Remnants
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Use of Laparoscopic Ultrasonography to Detect Ovarian Remnants

Farr Nezhat, MD, Camran Nezhat, MD, Ceana H. Nezhat, MD, Erika Sly, BS, RPMS, Daniel S. Seidman, MD
J Ultrasound Med, 15:487-88/1996

Abstract

Ovarian remnant syndrome is a complication of oophorectomy. It usually occurs in patients with distorted anatomy from adhesions and endometriosis, which makes surgical dissection difficult. The adhesions frequently result from pelvic inflammatory disease or previous pelvic operations. Although it is often technically difficult, resection is the most effective treatment for ovarian remnant syndrome. We have managed ovarian remnant syndrome successfully during laparoscopy. However, difficulty in diagnosing ovarian remnants during laparoscopy is not uncommon. Laparoscopic ultrasonography has been suggested to overcome the lack of tactile information. This technique has been used successfully to delineate the hepatobiliary anatomy during laparoscopic cholecystectomy, and for identifying hepatic and pancreatic malignancies. We report the use of laparoscopic ultrasonography to locate and monitor resection of bilateral ovarian remnants.

Use of Neutral Argon Plasma in the Laparoscopic Treatment of Endometriosis
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Use of Neutral Argon Plasma in the Laparoscopic Treatment of Endometriosis


Abstract

BACKGROUND AND OBJECTIVES: To report the feasibility and safety of the use of a novel energy source that uses an electrically neutral beam of pure argon plasma for the laparoscopic management of endometriosis.

METHODS: In this prospective pilot study, 20 patients undergoing laparoscopic treatment of endometriosis were included. Characteristic endometriotic lesions throughout the pelvis were vaporized or resected using neutral argon plasma. Specimens were evaluated for the presence of endometriosis and thermal effects on tissue. The bases of the treated lesions were biopsied to determine whether residual endometriosis was present.

RESULTS: Neutral argon plasma was used in 18 of the 20 patients for laparoscopic treatment of pelvic endometriosis. All biopsies confirmed complete vaporization or resection with no residual endometriosis at the base. Endometriosis was identified on pathology in all lesions excised. Thermal effects did not interfere with histologic analysis in any of the lesions. No complications occurred.

CONCLUSION: Neutral argon plasma can be utilized as a multi-functional device that has vaporization, coagulation, and superficial cutting capacities with minimal thermal spread and acceptable outcomes. The use of neutral argon plasma appears to be efficacious and safe for the complete treatment of endometriotic implants.

Related Information: Use of Neutral Argon Plasma in the Laparoscopic Treatment of Endometriosis

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Vaginal Extraction of Large Uteri Using the Alexis Retractor
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Vaginal Extraction of Large Uteri Using the Alexis Retractor


Abstract

Removal of large uteri via minimally invasive methods propose a number of challenges that can be diminished by technique, instrumentation, and skill of the surgeon. We propose that the Alexis Wound Retraction System, initially designed for circumferential and atraumatic retraction during abdominal surgery, is a viable alternative to standard retraction techniques when large uteri are removed vaginally.

Related Information: Vaginal Extraction of Large Uteri Using the Alexis Retractor

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Vaginal Vault Evisceration After Total Laparoscopic Hysterectomy
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Vaginal Vault Evisceration After Total Laparoscopic Hysterectomy

Ceana H. Nezhat, MD, Farr Nezhat, MD, Daniel S. Seidman, MD, & Camran Nezhat, MD
Obstetrics & Gynecology, 0029-7844/96, SSDI 0029-7844(95)00482-3

Abstract

Vaginal vault rupture with intestinal herniation, although rare, has been reported after vaginal and abdominal hysterectomies. We report three such cases, two postcoital and one spontaneous, after total laparoscopic hysterectomy.

Videolaseroscopy
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Videolaseroscopy

Camran Nezhat, MD, Farr Nezhat, MD, and Ceana Nezhat, MD
Clinical Practice of Gynecology:2, 137-145, 1990

Abstract

Since the introduction of endoscopy in 1910, there has been a dramatic change of pattern and approach to the diagnosis and treatment of various diseases of the reproductive organs. Recent advances in the techniques of operative endoscopy and high-technology instrumentation (such as endoscopes, videocameras, and videomonitors) have made it possible to perform endoscopically almost all of the infertiltiy and noninfertility related procedures that previously required laparotomy.

Videolaseroscopy and laser laparoscopy in gynaecology
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Videolaseroscopy and laser laparoscopy in gynaecology

Nezhat C, Hood J, Winer W, Nexhat F, Crowgey SR, Garrison CP
Fertility and Endocrinology Center, Atlanta, Georgia

Abstract

Laser laparoscopy has greatly expanded the potential applications of laparoscopy in gynaecology. Videolaseroscopy is a new refinement in the technique, which we believe is beneficial, not only to the patient, but also to the treating physician and the operating room staff. The clinical results of the beneficial application of this technique in the treatment of endometriosis and other diseases of the reproductive organs will be presented.
PMID: 2960410 [PubMed – indexed for MEDLINE]
Related Information: Videolaseroscopy and laser laparoscopy in gynaecology

Videolaseroscopy for Endometriosis
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Videolaseroscopy for Endometriosis

Camran Nezhat, MD, Wendy K Winer, RN, BSN, Farr R. Nezhat, MD Ceana Nezhat, MD
Lasers in Endoscopy, Chapter 9

Abstract

Operative laparoscopy is a cost effective and clinically efficacious technique in the treatment of endometriosis. The CO2 laser is useful in situations requiring precise application, safety, and minimal tissue damage. The fine beam provides precise control for vaporization or dissection of endometriosis through the laparoscope. The use of the CO2 laser through the laparoscope was first reported by Bruhat, Mage and Manhes in 1979 and later by Tadir. Incorporation of the videocamera and laparoscope in human and animal studies has been described and the advantages have been noted. Previously, due to the weight of the cameras, low resolution of both cameras and monitors and high cost, videocameras had not been widely used in gynecology.

Videolaseroscopy for oophorectomy
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Videolaseroscopy for oophorectomy

Nezhat F, Nezhat C, Silfen SL.
Fertility and Endoscopy Center, Atlanta, GA.

Abstract

Laparoscopic oophorectomy was performed on 94 ovaries in 76 patients. Indications included recurrent pain associated with endometriosis and adhesions in 17 patients (18 ovaries), ovarian endometriomas in 40 patients (40 ovaries), prophylactic oophorectomy (breast cancer) in one patient (2 ovaries), removal of the ovaries at the time of laparoscopic assisted vaginal hysterectomy in 15 patients (30 ovaries), and other indications in three patients (four ovaries).
PMID: 1835564 [PubMed – indexed for MEDLINE]
Related Information: Videolaseroscopy for oophorectomy

Videolaseroscopy for the treatment of endometriosis associated with infertility
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Videolaseroscopy for the treatment of endometriosis associated with infertility

Nezhat C, Crowgey S, Nezhat F.
Fertility and Endocrinology Center, Atlanta, Georgia 30342.

Abstract

Recent advances in laparoscopic surgery have enabled the gynecologic surgeon to treat an increased number of diseases of the reproductive organs by using the laser through the laparoscope. This article reviews the results of 243 patients with infertility associated with endometriosis ranging in severity from mild to extensive who were treated by the same surgeon using CO2 laser laparoscopically with videocamera augmentation and control. Of the 243 infertility patients, 168 (69.1%) achieved pregnancy. The pregnancy rates were 71.8% in 39 patients with stage I disease, 69.8% in 86 patients with stage II disease, 67.2% of 67 patients with stage III disease, and 68.6% in 51 patients with stage IV disease. The life table and two-parameter exponential model were used to calculate monthly fecundity, “cure,” and “probability of pregnancy” rates. The results indicate that videolaseroscopic treatment of endometriosis associated with infertility, in surgically experienced hands, is at least as efficacious as other forms of therapy for mild and moderate cases of disease, but appears to be more successful than laparotomy for the more severe and extensive stages of disease.
PMID: 2912770 [PubMed – indexed for MEDLINE]
Related Information: Videolaseroscopy for the treatment of endometriosis associated with infertility

Videolaseroscopy: A new Modality for the Treatment of Endometriosis and Other Diseases of Reproductive Organs
MORELESS

Videolaseroscopy: A new Modality for the Treatment of Endometriosis and Other Diseases of Reproductive Organs

Camran Nezhat, MD
Colposcopy & Gynecologic Laser Surgery, Volume 2, Number 4, 1986

Abstract

In the present study, a total of 311 patients underwent videolaseroscopy for a 12 month period. Of these, 257 patients had endometriosis (stage I to IV/AFS), and 54 patients had other pelvic pathology, such as adhesions or tubal disease. For the procedures discussed herein, the CO2 laser was used almost always through the operating channel of the laparoscope via an especially designed coupler by Cabot Medical (Nezhat coupler) or, occasionally, through a specially adapted second puncture trocar. A micromanipulator coupler was attached to the laparoscope or to the second puncture probe.

Videolaseroscopy: The CO2 Laser for Advanced Operative Laparoscopy
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Videolaseroscopy: The CO2 Laser for Advanced Operative Laparoscopy

Camran R. Nezhat, MD, FACOG, Farr R. Nezhat, MD, FACOG, and Sheryl L. Silfen, MD, FACOG
Obstetrics and Gynecology Clinics of North America, Vol. 18, No. 3, 9/1991

Abstract

Advanced operative laparoscopy offers an appealing alternative to laparotomy for benign gynecologic disease. By eliminating a large abdominal incision, a laparoscopic surgical procedure generally requires short-stay hospitalization of less than 24 hours and allows full recovery in less than a week. Patients prefer laparoscopy intuitively because it is less painful and cosmetically acceptable; furthermore, patients perceive surgery done by laparoscopy as less invasive physically and less intrusive in their lives. Surgeons can visualize deep pelvic structures more easily and produce less de novo adhesions than with laparotomy, preserving patients’ future fertility. Health care costs are reduced, and workers return to full productivity rapidly. Thus, in the hands of a skilled, experienced operative laparoscopist, advanced operative laparoscopy is universally preferable to laparotomy for appropriately selected cases.

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